Clinical Methods in Medicine: Clinical Skills and Practices SN Chugh, Eshan Gupta
Page numbers followed by f refer to figure, t refer to table and b refer to box
Abdomen 246
acute 292
differential diagnosis of 291t
auscultation 272f, 272
common abnormalities 253, 257
dilated veins 252b
general physical examination 249
inspection 250
palpable structures 246f, 246
palpation 256
deep 257f, 257
superficial 256
percussion abnormalities 269
regions of 246f
shape of 251
Abdominal aorta 246
aneurysm 205t
Abdominal distension 19b, 23, 247b
Abdominal lump 265
physical examination of 265
Abdominal movements 254
Abdominal pain 28, 247b
causes 20t
precipitating factors 20b
relieving factors 20b
Abdominal paracentesis 289
Abdominal pulsations 250
Abdominojugular reflux 174
Abductor pollicis brevis 379t
Abnormal bowel sounds 273
Abscess 237t
Acanthosis nigricans 69t
Accessory muscles of respiration 221, 222
abdominal muscles 223
alae nasi 223
latismus dorsi 223
pectoralis major 223
scalani 223
serrotus anterior 223
sternomastoid 223
trapezius 223
Achondroplasia 54t, 54b
Acne vulgaris 76f
Acoustic neuroma 114b, 119
Acrocyanosis 204b, 205
Acromegaly 45b, 52f, 52t, 73t, 144b, 147t, 150, 152t, 506, 516, 523f, 523
Acromioclavicular joint 449
ACTH 517
deficiency 526t
Actinomycetes 220b
Added sounds 184, 186f, 211, 229, 232
types of 232
Addison's disease 41t, 46, 60t, 70b, 71, 73t, 151b, 416, 506, 509, 512, 525f, 525t, 525
Addisonian crisis 418t
Additional sounds 182
ADH deficiency 526t
Adie's pupil 93
Adiposogenital syndrome 507t
Adnexal masses 321
Adrenal axis 517
Adrenal crisis 22t
Adrenal disease 140t
Adrenalectomy 73t
Adson's test 201
Agranulocytosis 35
AIDS 47t, 217t, 299b
associated enteritis 24t
Albinism 69, 71f, 92
Alcohol related disorders 11b
Alcoholic dementia 11b
Alcoholic hepatitis 11b
Alcoholism 70b
Alkaline phosphatase 285
Allen test 29f, 201, 204
Allergic alveolitis 35
Allergic contact dermatitis 68b
Allergic rhinitis 217t
Allodynia 44b, 332
Alopecia 18t
areata 80, 80t, 81f
classification of 80t
Alpha 1-antitrypsin 286
Alport's syndrome 297, 298, 301, 302
Alveolitis 217
Amaurosis fugax 84b, 203, 337t
Amblyopia 95t
Amenorrhoea 17t, 44b, 300
Amnesia 338b
Amoebiasis 299b
Amoebic dysentery 7
Amoebic liver abscess 19f
Amyloidosis 152t, 155, 435t
Anaemia 9t, 25, 32, 41t, 151b, 177, 180, 200, 218, 220, 295, 297, 300, 470, 471, 489t
aplastic 35, 37b, 121b
causes of 471t, 471
deficiency 472t
dimorphic 471
folic acid 472t
haemolytic 262, 472t
hypoplastic 472t
iron deficiency 472t
leucoerythroblastic 474
macrocytic 471
hypochromic 471
megaloblastic 73t
normocytic normochromic 471
pernicious 479b
symptoms and signs of 470b
vitamin B12 deficiency 472t
Anaesthesia 44b, 332
Anal fissure 24, 24t, 277
Anal skin tags 277
Anal warts 276, 277
Analgesia 332
Androgen receptors
antagonists 49t
defects 49t
Androgenic alopecia 80t
Aneurysmal disease 205
Angina pectoris 31t
Angiography, pulmonary 244
Angioneurotic oedema 53b, 157t
Angiotensin-aldosterone system 156
Angiotensin-converting enzyme inhibitors 140t
Angle of louis 212
Angular stomatitis 342
Anhydrosis 94t
Anisocoria 93
Ankle and foot, examination of 463
Ankle 461
jerk 384
testing of movements of 464
Ankle/brachial pressure index 203
measurement of 205
Ankylosing spondylitis 32b, 50, 248, 434, 442, 442b
Anorectal disorders 276
Anorexia 19b, 25, 247b
Anorexia nervosa 17t, 45, 48t, 56
Anorexia-bulimia 57
Anosmia 54t, 351
Anotia 116
Anterior axillary line 213f, 213
Anterior cerebral artery, syndrome of 337, 338b
Anthropometry 57
Antinatriuretic hormone 157
Antineutrophil cytoplasmic antibodies 466
Antinuclear antibodies 466
Anti-RNA polymerase antibodies 466
Antithrombin III 304
Anuria 38, 298
Anus 276
inspection 277
palpation 277
Anxiety 489t
Anxiety neurosis 31t, 32
Aorta 192
Aortic aneurysm 30t, 178, 255, 265, 267b, 442b
Aortic diastolic murmur 31t, 181
Aortic dissecting aneurysm 31t
Aortic dissection 20t, 30t, 181b
Aortic ejection systolic murmur 175
Aortic regurgitation 165t, 168b, 170t, 183, 186, 187, 195
acute 19f
Aortic stenosis 164t, 165t, 170, 175, 180, 184, 186b
Aortic valves 162, 177t, 181
Aortic valvular stenosis 181b, 187t
Aortoiliac aneurysm 200b
Aortopulmonary window 165t, 187t
Apex beat 178, 179
causes of displaced 180b
character of 179
localisation of 179f
palpation of 179f
APGAR score 492
Aphasia 337t, 349
global 349
Broca's 349t
testing for 348t
Wernicke's 349t
Apical impulse 162
Apical lung neoplasm 441b
Apnoea 33, 216b
Apocrine glands 67
Appendicitis 19, 20t, 258b
acute 19f, 21t
Appendicular mass, characteristics 266
Apraxia 349
constructional 349
dressing 349
gait 349
ideomotor 349
Aqueductal stenosis 359b
Aqueous humour 83
Arachnodactyly 147, 148f, 148t
Arachnoid mater 62, 326
Arachnodactyly 54t
ARDS 27b
Argyll-Robertson's pupil 93, 94t, 95
Arrhythmias 26, 172t, 197
Arterial bruits 186
Arterial insufficiency 209t
Arterial pulse
anacrotic 170t
arterial wall 169
character 166
characteristic 170t
Corrigan's pulse 170, 171f, 171t
dicrotic pulse 170t
irregularly irregular pulse 168b
normal 170t
pulse rate 167b
alternans 170t
bigeminus 170t
bisferiens 170t
paradoxus 170t
radiofemoral delay 166, 169
rate 166
regularly irregular pulse 168b
rhythm 166, 167
volume 168
Arteriosclerosis 169
Arteriovenous anastomosis 300
Arteritis 199
Arthralgia 427t
Arthritis 50, 175, 426, 427t, 444b
causes of 50b
Arthrogram 468
Arthropathy 426
Articular processes 440
Asbestosis 217t
Ascending aorta 192
Ascites 14t, 25b, 26t, 53, 157b, 219t, 236, 248b, 253, 269, 304
fluid thrill 270, 271f
horse-shoe shaped dullness 270, 271f
Pudal's sign 270, 271f
shifting dullness 270, 271f
Aspergilloma 30t, 217t
Asthenia 43b
Asthma 6, 8t, 18, 28, 29b, 32, 33, 34t, 35, 69, 178, 179, 211, 217, 217t, 222, 223b, 240, 241t
acute 36t
bronchial 7, 218, 223, 225, 225t, 231, 233, 237
cardiac 233, 234t
chronic 33t
occupational 216b
Asymmetrical oligoarthritis 430t
Ataxia 371
causes of 392b
Atelectasis 224
Atheroembolism 204
Atheroma 335f
Atherosclerosis 55t, 169, 193, 198, 302
Atherosclerotic obliterans 199
Athetosis 40b, 395t
Atlantoaxial joint 442t
Atopic eczema 68b
Atrial fibrillation 26, 27, 167b, 168, 184
causes of 168t
Atrial flutter 167b
Atrial myxoma 184b, 199
Atrial septal defect 165t, 184b, 187, 193, 195 197
Atrial thrombus 199
Atrioventricular fistula 198t
Atrioventricular malformations 205t
Atrioventricular valves 162
Audiometry 119, 120
pure tone 120
speech 120
Auditory acuity 117
Auricle examination 116
Auscultation, method of 229, 230f
Automatism 16t
Autonomic dysfunctions, symptoms of 405b
Autonomic hyperactivity 418t
Autonomicnervous system 402
aetiology of 404t
disorders 402
Autosomal recessive disorders 7
AV block first degree 184b
Axillae 137143
examination 143
inspection 143
palpation 143
Axillary nodes 137t
Axons 325
Azotemia 298
Babinski's response 387
Babinski's sign 329, 382t, 387
Back 275
Bacteriuria 310
Balanitis 313
Balanoposthitis 313
Barium meal studies
enema 279
swallow 278
Barrel shaped chest 178, 221t
Bartholin's gland abscess 318
Bartter's syndrome 298
Basal cell carcinoma 70f
Basal ganglia 325, 326, 375, 406t
Becker's muscular dystrophy 374f
Behçet's syndrome 435t
Bell's palsy 364, 366t, 366
Bence-Jones protein's, test for 534
Benedickt's syndrome 338t
Benedict's test 307, 534
Benign cholestasis 26t
Benign intracranial hypertension 63t
Benign prostatic hypertrophy 278
Benzidine test 536
Berger's disease 297
Beri-beri 157t
Berylliosis 217t
Beta blockers 47t, 198, 204, 402
Biceps 380t
Bilateral diaphragmatic paralysis 222
Bile pigments, tests for 307
Bile salts, test for 536
Biliary cirrhosis 26t, 68b, 73t, 150b
Bilirubin 90, 282, 307
tests for 307
Bimanual palpation 259b
Biot's breathing 218b
Bird fancier's lung 217t
Bitot's spots 90, 90f
Bleeding 35
causes of 37b
disorders 9t
gums 37
per rectum 19b, 23
Blepharitis 85b, 87, 510
Blood 470
Blood culture 531
Blood in urine, tests for 305
Blood loss signs and symptoms 37t
Blood pool scanning 196
Blood pressure 169
checklist for 169
diastolic 169
specific problems related to 172t
systolic 169, 203
BMI 5355, 56b
Boiling test 533
Bone density 468
Bone marrow
aplasia 15t
examination 482
chief indications for 483b
Bone pain 429
Bone scanning 410
Bony ankylosis 435, 439
Bouchard's nodes 151b, 151f
Bowel sounds, auscultation of 272f
Bowman's capsule 294
Bowstring sign 447f, 447
Brachial pressure index 199
Brachioradialis 380t
Bradycardia 59b, 167b
arrhythmic 167b
sinus 167b
Brain 325
abscess 63t, 236
blood supply 334
death 421f
diagnosis of 424t
testing 423
Brainstem 325, 356, 422
infarction 116
tumours 120
Brainstem reticular activating system (RAS) 415
BRCA1 138
BRCA2 138
Breast 137143
lactational abscess (ES) 138
nonlactational 138
atrophy 25
carcinoma 137
risk factors 137
TNM classification 137t
cysts 138
examination of 140, 512
fibroadenomas 138
fibrocystic disease 138
lump 137t, 137
lymphoedema 138
stages of development 136f
Breast disease
investigations 143
fine-needle aspiration 143
mammography 143
MRI 143
trucut biopsy 143
ultrasound 143
symptoms 137
Breath sounds 230
bronchial 231f, 231t, 231
bronchovesicular 231t
characteristic of 231
intensity of 230b
vesicular 231f, 231t, 231
Breathing abdominal 221
Breathing patterns, in respiratory disorders 218b
bronchial 231, 232t
causes of 232t
slow 218b
thoracic 221
Breathlessness 32, 216b
Brisk tendon stretch reflexes 329
Brissaud's reflex 387
Broca's area 347
Bromsulphalein (BSP) clearance 286
Bronchial adenoma 30t
Bronchial asthma acute 34t
Bronchial carcinoma 29b, 30t, 33
Bronchial tree 214
Bronchiectasis 29b, 30t, 150b, 217t, 218, 223b, 225, 234, 237t
Bronchitis 7, 10f, 29b, 30t, 222, 223, 223b, 237t
acute 31t
chronic 30, 231, 234t, 240
Bronchogenic carcinoma 10f, 150b
Broncholitis 241t
Bronchophony 229b, 232
Bronchopleural fistula 225t, 232
Bronchopneumonia acute 27b
Bronchopulmonary aspergillosis 238
Bronchoscopy 243
Bronholm disease 30t
Brudzinski's sign 350f, 350
Bruises 37
Bruit 520
Budd-Chiari syndrome 20t, 25, 26t, 157t, 260
Buerger's disease 153, 199, 204f, 204
Buerger's test 201
Bulbar conjunctivae 89
Bulbar palsy 23b, 338t, 369b, 371
Bulge sign 460
Bursae 427
Bursitis 50b
Café-au lait spots 342, 444t
Calcitonin 133
Calcium channel blockers 140t, 167b
Caloric test 120, 121
Campbell de Morgan spots 250
Canal of Schlemm 83
Candida albicans 533
Candida spp 533b
Candidiasis 23b, 68b, 147t
cutaneous 74
Capillary naevus 78f
Caput medusae 25
Carboxyhaemoglobin 73
Carcinoid syndrome 17t, 24t, 68b, 234t
Carcinoid tumour 68b
Carcinoma 140t
bronchus 217t
penis 313
rectum 19f
stomach 69t
Cardiac achalasia 22, 23t, 228, 233
Cardiac arrhythmias 188
Cardiac catheterisation 196
Cardiac cycle 162f, 162, 163
Cardiac disease 28
Cardiac dullness 161, 227
Cardiac ischaemia 441b
Cardiac murmurs 163
Cardiac rupture 192
Cardiac tamponade 41t
Cardiomegaly 157b, 227, 470b
Cardiomyopathy 11b, 26, 168t, 199
Cardiovascular symptoms 25
Cardiovascular system 162f, 162
general physical examination 164, 165
investigations 187
systemic examination 161
Carditis 176b
Carotenaemia 70
Carotid artery 135, 173t, 175
dissection 200b
stenosis 205t
Carotid pulse 126, 163, 173t, 175, 211, 219, 249
palpation of 176f
Carpal tunnel syndrome 152t, 524t
Carpometacarpal joint 428b
Carrey-Comb's murmur 187t
Cataract 84b
complications 197t
contraindication 197t
indications 197t
Cauda equina 326
Cauda equina syndrome 442
Caudate nucleus 325
Cavernous haemangioma 77
Cavernous sinus 339, 356, 361t
thrombosis 85f, 88t, 95
Central artery of retina 100
Cerebellar ataxia 389, 402
Cerebellar lesions 406t
Cerebellopontine angle 361t
Cerebellum 325, 326, 328
Cerebral abscess 410b
Cerebral angiography 409
Cerebral artery
anterior 334
middle 335
posterior 336
Cerebral cortex 330b
Cerebral embolism 28
Cerebral hemispheres 347
Cerebral infarcts 410
Cerebral lacunar infarcts 371
Cerebral malaria 420
Cerebral tumour 410b
Cerebral venous sinus thrombosis
causes of 340b
clinical manifestations 340t
Cerebrospinal fluid 326
Cerebrovascular disease 197
Cerebrum 325
Cervical carcinoma 317
Cervical lymphadenopathy 211, 219
Cervical rib 441b
Cervical smear 321
Cervical spondylosis 441b
Chaddock's sign 388b
Chagas' disease 23t
Chancroid 299b, 313, 314f
Charcot arthritis 50b
Charcot's joint 435
Charcot-marie-tooth 152
Cheese worker's lung 217t
Chemosis 520
Chest examination 220244
anterior chest 220
auscultation 229235
inspection 220223, 234
palpation 223225, 235
percussion 225229, 235
lateral chest 220
posterior chest 234236
Chest pain 27, 28b, 30, 33
atypical 32
causes of 30t
differential diagnosis of 31t
pleural 32b
Chest wall
lesion 221
posterior 212f, 213b
anatomical landmarks 213b
deformities 221t
fluoroscopy of 238
important regions on 215b, 216f
movements of 221
normal shape of 220b
X-ray 191
of 239b
indications of 192
Cheyne-stokes breathing 218b, 421
CHF 165, 219t, 262, 479b
Chicken pox 6, 76f, 74
Chilaiditi's syndrome 269
Chlamydia trachomatis 533b
Cholangitis, acute 21t
Cholecystitis 8t, 22t, 258b, 443b
acute 19f, 22t
chronic 261
Cholelithiasis 261
Chorea 392, 395t
causes of 395b
Huntington's 395t
Sydenham's 395t
Christmas disease 37b
Chronic intestinal pseudo-obstruction 24t
Chvostek's sign 397
Chyluria 298
Ciliary body 83
Ciliospinal reflex 94t
Circle of willis 335f, 334
Cirrhosis of liver 8t, 11b, 49t, 80t, 140t, 157t, 271
Citrullinated cyclic peptide (CCP) antibodies 465
Claude syndrome 338t
Claudication 200t
arterial 199, 200t
neurogenic 199, 200t
venous 199, 200t
Claw foot 152
Claw hand 144b
Clinitest 307
Clonus 375
Close-angle glaucoma acute 85b
Clubbing 145, 150, 177, 211, 219
causes of 150b
differential 150
Coagulation pathways 482
Coal worker's pneumoconiosis 217t
Coarctation of aorta 169, 172t, 178, 220b
Coccyx 440
Cochlear nuclei 367
Cochlear otosclerosis 114b
Coeliac disease 8t, 54t, 55f, 508
Coeliac sprue 24t
Coin test 233
Colic 20t
Colitis 19f
Collagen diseases 121b
Collagen vascular disorders 50b
Collateral ligaments 459
Colonic carcinoma 24t
Colonoscopy 281
Colour vision 92
abnormalities of 92b
Coma examination, brainstem reflexes 422f
Coma like syndromes 415
akinetic mutism 415
catatonia 415
coma vigil 415
hysterical pseudocoma 415
locked-in-state 415
vegetative state 415
Coma scale, Glasgow 419b
Coma 415
abnormal posturing 419
causes of 415
cause of 418t
evaluation of a patient 416
common causes of 416
due to encephalitis 420f
eye movements in 421
general physical examination 417
head injury 420
hepatic 419f
immediate assessment of 417t
investigations 423
metabolic clinical features 418b
clinical features 418b
examination 417
ocular fundus examination 423
pupillary size and reaction 421
without neurological signs 423b
Complete heart block 167b, 173
Conduction defects 188
Conductive deafness 114
Congenital adrenal hyperplasia 48t
Congenital heart disease 8t, 54b, 59b, 150f, 150, 167b, 168t, 194
Congenital hyperbilirubinaemia 26t
Congestive cardiac failure 33, 161, 164, 168b, 175f, 175, 184
Conjugated hyperbilirubinaemia 282
Conjunctiva 83, 86, 89
Conjunctival chemosis 218, 219t
Conjunctivitis 85b, 301, 510
Conn's syndrome 509, 515t
Consciousness 344
Consolidation 225, 225t
Constipation 19b, 22, 24, 247b, 402
Constrictive pericarditis 157t, 168t, 174, 175
Constructional apraxia 346f
Convulsions 40b
COPD 7, 30, 32b, 33, 33t, 3436, 178, 179, 183, 192, 193, 217220, 222, 225, 233, 234t, 240, 241, 244
risk factors for 217f
COR pulmonale 168b, 168t, 219
Cornea 83, 86, 90
Corneal arcus 200b
Corneal blink reflex 422
Corneal oedema 90
Corneal reflex 361
Corneal ulceration 85b
Coronary angiography
complications 196, 197t
contraindications 196, 197t
indications 196, 197t, 198t
Coronary arteriovenous fistula 164, 187t
Coronary artery disease 7, 8t, 168t, 198t
Corticobulbar fibres 327
Corticospinal tract 327
Costochondritis 30t
Costophrenic angle 247
Costovertebral joints 446
Cough 28, 216b
barking 53
brassy 53
characteristics of 29b
reflex 422
whooping 53
Courvoisier's law 261
Crackles 211, 229b, 232, 233
causes of 234t
coarse 235t
early inspiratory 234t
expiratory 234t
mid-inspiratory 234t
palpable 225
Cranial nerves 62, 65, 113, 326, 406
abducens 327b, 354, 355
nerve palsy 358
accessory 368, 369
common abnormalities 370
motor innervation 368t
parasympathetic innervation 368t
reflex 368t
sensory innervation 368t
examination of 351
facial 327b, 363
nerve paralysis 366t
palsy 363, 365f
functions 327b
glossopharyngeal 327b
common abnormalities 370
motor innervation 368t
nerve palsy 368, 369
neuralgia 368
parasympathetic innervation 368t
reflex 368
sensory innervation 368t
hypoglossal 327b, 370
nerve palsy unilateral 370, 371
nerve palsy, bilateral 371
oculomotor 327b, 354
palsy 89t, 95, 421
olfactory 327b, 351
optic 327b, 351
spinal accessory 327b
trigeminal 327b, 359
mandibular 360
maxillary 360
nerve disorders 361t
ophthalmic 360
palsy 90
trochlear 327b, 354, 355
nerve palsy 358
vagus 327b
common abnormalities 370
motor innervation 368t
nerve palsy 368
parasympathetic innervation 368t
reflex 368t
sensory innervation 368t
vestibulocochlear 327b, 364
cochlear functions 367
vestibular functions 367
Craniopharyngioma 48t, 54b, 100b, 353t, 526t
Creatinine 310
Crest syndrome 200b
Cretinism 54
Cricoid cartilage 511b
Criggler-Najjar syndrome 25, 282
Crohn's disease 24t, 54b, 150b, 248, 508
Cruciate ligaments 459
Cruveilhier-Baumgarten syndrome 273
Cryptorchidism 47t, 49t, 49, 317, 318f, 318t, 513, 514t
CSF examination 424
CT scan, diagnostic value of 407b
Cushing's syndrome 17t, 45b, 45t, 52t, 53b, 55, 70b, 73t, 88, 157t, 251, 506, 507t, 509, 515, 524t, 524f, 524
Cutis vulgaris 220b
Cyanosis 14t, 34t, 73, 157b, 165, 165b, 200, 204, 211, 218, 219
central 36t, 165, 166
mixed 166
peripheral 165, 219
Cyanotic heart disease 205, 340b
Cyst of epididymis 317t
Cystic fibrosis 47t, 54b, 508
Cystic medial necrosis 192
Cystic renal diseases 39t, 298
Cystitis 20t, 39t, 264
Cystocele 318
Cystourethrocele 319
Dacryocystitis 85b, 89
Deafness 114
causes of 114b
conductive 367
sensorineural 367
Debre-Kocher-Semelaigne syndrome 45b
Deep tendon reflexes 330t, 330
Deep vein thrombosis 34t, 206, 207f, 207, 210, 217t
clinical manifestations of 207t
complications 208
differential diagnosis 208
investigations 207
of arm 207t
of leg 207t
Degenerative disorders 428b
Dehydration 59b
Deltoid ligament 461
Deltoid reflex 384
Demyelinating optic neuritis 103
Dendritic cells 67
Depression 489, 490f, 490t
Dermatitis artefacta 69t
Dermatitis herpetiformis 69t
Dermatome 333
Dermatomyositis 73t
Dermatophytes 533
Dermis 66, 67
Descending aorta 178
Dexamethasone suppression test 503, 517b, 517
Dextrocardia 179
Diabetes insipidus 6b, 17t, 44, 45t, 59b, 303
nephrogenic 6b, 44, 303
Diabetes mellitus 6, 6b, 7, 8t, 16, 17t, 18, 24t, 38, 56, 59b, 80t, 161, 198, 298, 300b, 306, 416, 506, 526, 528, 527f
diagnostic criteria 526b
type 2 528b
clinical presentations 528b
Diabetic coma 418t
Diabetic dermopathy 509
Diabetic foot 154f, 528b
Diabetic ketoacidosis 20t, 32, 33, 416
Diabetic myopathy 45b
Diabetic nephropathy 309
Diabetic retinopathy 84b, 102b, 102f, 102
Diadochokinesis 390
Diaphragmatic paralysis 254
Diaphragmatic pleurisy 19
Diarrhoea 19b, 20, 22, 24, 43b, 247b
Diarrhoea acute, causes of 23t
Diarrhoea chronic, classification of 24t
Diarrhoea nocturnal 402
Diastasis recti 254f, 254
Diastolic murmur 182
Diencephalon 325
Differential leucocyte count 481
Diffuse proliferative glomerulonephritis 309
Dilatation acute 193
Dilated cardiomyopathy 168b, 170t, 180, 192
Dilated pupils 418t
Dinner-fork deformity 394
Dip stick test 304
Diphtheria 124, 222
Diplopia 84, 85, 87, 88t, 95, 121, 394t
binocular 85
causes of 86b
monocular 85
Dipstick test 534, 536
Disc protrusion 442
Discoid lupus erythematosus 80t
Distal interphalangeal joints 428b, 453
Distant vision, tests for 91
Diuretic therapy 6b
Diverticular disease 24t
Diverticulitis 20t, 21, 24
acute 21t
Diverticulosis 269, 443b
Dix and Hallpike method 119
Doll's eye reflex 367
Donovanosis 313, 314f
Double apex beat 180
Dowager hump 442
Down's syndrome 52f, 52t, 54b, 147t, 148f, 151b, 508
Drum examination 117
Dry eye syndrome 90
Dry tongue 59
Dubin-Johnson syndrome 307
Duchenne muscular dystrophy (DMD) 374b, 374f, 375
Duodenal ulcer 19f
Duodenum 267b
Duplex venous ultrasonography 207
Dupuytren's contracture 435, 437f
Dura mater 326
Dural sinus thrombosis 101t, 339
Durkan's sign 456
Dwarfism 508
Dysaesthesia 44b, 332
Dysarthria 347
causes of 348t
Dysdiadochokinesis 329
Dyshormonogenesis 18t
Dysmenorrhoea 20t
Dyspepsia 19b, 247b
causes 21t
nonulcer 20b
Dysphagia 19b, 20, 22, 46, 124, 211, 216b, 219t, 247b, 511
causes 23t
differential diagnosis of 23b
mechanical 23b
motor 23b, 23t
neuromuscular 23t
oropharyngeal 23t
Dysphasia 347, 349
Dysphonia 124, 216b, 347, 349
causes of 124b
Dyspnoea 14t, 15, 15t, 16, 25, 26, 28b, 32, 35, 36b, 161, 164, 216b
at rest 27
cardiac 35, 36t
causes of 27b, 33, 33t
characteristics 33
due to respiratory disease 32
pulmonary 36t
Dystonia 40b, 396
Dystrophic myotonia 317t, 357t
Dysuria 37b, 38, 293, 298
Ear 113121, 116f
canal examination 117
examination of 116
functions 113
Ecchymosis 36b, 37, 478t
Ecchymotic patches 480f, 480
Eccrine glands 67
conventions 189b
indications of 188
Echocardiographic values, normal 194t
Echocardiography 187, 194
Doppler 195f, 195
colour flow mapping 196
continuous wave Doppler 195
pulse wave Doppler 196
M-mode 194f, 194
stress 189
two-dimensional 194, 195f
Eczema 69
Edinger-Westphal nucleus 355
Ehlers-Danlos syndrome 435, 464
Ehrlich's aldehyde test 307, 535
Eisenmenger's syndrome 150, 150b
Ejection clicks 184, 186b, 186f
causes of 186b
Elbow 451
examination of 452
movements testing at 452
tunnel syndrome 404b
Electroencephalography (EEG) 410
Electromyography (EMG) 410
Electronystagmography 119
Electrophoresis of proteins 304, 305f
Electroretinograms 103
Embolisation 197
Emphysema 36t, 101t, 223, 223b, 224, 225t, 232, 237, 269
subcutaneous 220b
Empyema 220
Encephalitis 63t, 114, 416, 418b, 420, 423, 424
Encephalitis lethargica 422
Encephalocoele 64b
Endocarditis 165, 181b, 262
bacterial 199f
Endocrinal diseases
common presenting symptoms of 507t
general physical examination (GPE) 508
physical signs of 508t
systemic examination in 515t
Endocrinal imaging 518
Endocrine system 505
Endometritis 20t
Endophthalmitis 85b
Endoscopic retrograde cholangio-pancreatography (ERCP) 280, 288
Endoscopy 279, 289
lower GI 281
upper GI 279
Enophthalmos 87
Enterohepatic circulation 307
Entrapment neuropathies 402, 404b
Enuresis 39
nocturnal 39
Eosinophilic gastroenteritis 24t
Epidemic myalgia 30t
Epidermis 66
Epididymis 316
Epididymo-orchitis 317t
Epigastric pulsations 178, 180f, 180
Epiglottis 124
Epilepsy 8t, 40, 40b, 211, 340, 410b
Epileptic fit 42t
Epiphora 84
Episcleritis 85b
Epistaxis 37, 35t, 121
causes of 121b
Erector spinae 382t
Erosive gastritis 8t
Eruptive xanthomas 509
Erysipelas 122
Erythema marginatum 176, 176b, 176f
Erythema nodosum 69t, 70f, 220b, 248, 435t
Erythropoietin 295
Ethmoidal sinuses 360
Eunuchoidism 54t, 509, 513f
Eustachian tube 114
Exanthematous fever 7
Exocrine pancreatic function 282
Exophthalmic ophthalmoplegia 86b, 88, 507t
Exophthalmos 84, 87, 88f, 90, 510, 520
bilateral 88
causes 88t
unilateral 88
Extension 445
Extensor plantar responses 329
External auditory canal 117
External auditory meatus 117
External blunt trauma 113b
External jugular vein 172, 175
External ocular muscles, functions 356f
External strabismus 357
External urethral meatus 313
Extramedullary erythropoiesis 476
Extraocular muscles, paralysis 86
Extrapyramidal lesions 329
Extra-respiratory muscles 211, 218
Extremities, examination of 144157
Extrinsic allergic alveolitis 217t
Eye 83103
examination 86, 510
abnormal findings 86
general inspection 87
internal examination 92
iris 92
pupils 92
Faecal impaction 24t
Faeces, examination of 532
Fallot's tetralogy 150, 165t, 193
Familial urate nephropathy 298
Farmer's lung 217t
Fasciculations 397
Fatigue 28
Fatty abdomen 253
Feet, examination 151
Felty's syndrome 435t
Femoral nerve stretch test 448f, 448
Ferric chloride 535
Fetor hepaticus 25, 25b, 252b
Fever 60
types of 61f, 60
Fibrillations 28, 397
Fibromyalgia 50b, 223b
Fibromyositis 43b
Fibrosing alveolitis 150b
Fibrosis 220, 224, 237t
lung 232t
Fibrositis 43b
Fibrous ankylosis 439
Filariasis 157t
clubbing of 165b, 166
deformities 147t
joints 455
Finger to finger test 389
Finger-nose test 389
Fistula 24
Flapping tremors 271f, 271, 301
Flat chest 220
Flatulent dyspepsia 13t
Flexion 445
Flexor retinaculum 453
Flexors/extensors, wrist 380t
Flip test 447, 448f
Floating ribs 213b
Fluoroscopy 194
Foetal alcohol syndrome 11b
Foot 461
Forced expiratory
time 243
volume 242f
Fornix 87
Foster-Kennedy syndrome 101t
Fovea centralis 83
Frenzel's glasses 119
Friction rub 273
Friedreich's ataxia 152
Frohlich's syndrome 45t, 55t
Frontal lobe lesion 406t
Frontal sinuses 123f, 123
Fructosuria 307
FSH 515b
abnormalties of 98
normal 97
Funnel chest 221t
Furunculosis 122
GB syndrome 375t
Gag reflex 368
Gait 43, 351, 434
antalgic 434
apraxia 392
examination of 391
painless 434
trendelenburg 434
types of 393t
waddling 434
Galactorrhoea 17t, 44b, 48, 139f, 139, 506, 513
common causes of 139b
Gallbladder 267b, 268
palpation 260
Gallstones 55t
GALS screening tests 432f
Gastric carcinoma 37
Gastritis 11b, 19f
acute 10f
Gastroesophageal reflux disease 20b, 23b, 30t, 489t
Gastrointestinal system 247
investigations of 278
symptoms 19, 247b
lower GI tract 247b
upper GI tract 247b
Gastroscopy 280
Gaze palsy 359b
General physical examination 51
built 53
complexion 51
facial appearance 51
gait 51
of height 53
of weight 53
mental state 51
nutritional status 57
odour 53
personal hygiene 51
speech 51
state of hydration 58
vitals 59
blood pressure 59
pulse 59
respiration 59
temperature 59
Generalised purpura 69t
Genital herpes 299b, 313t
Genital system 46
Genital warts 299b
Genitalia 295
external examination 317
inspection 317
internal examination 321
palpation 32
related symptoms 296b
male 295
examination 313
related symptoms 296b
Genito urinary system
examination of abdomen 300, 302
auscultation 300, 302
inspection 302
palpation 302
percussion 302
examination of genitalia 300, 513
general physical examination 300302
Genitourinary symptoms 296
Genu valgum 460
Genu varum 460
Gerhardt test 307
GH deficiency 516, 526t
Giardiasis 299b
Gibbus 444
Gigantism 54b, 54t, 55f, 144b, 342, 523f, 523
Gilbert's syndrome 25, 282
Gille de la Tourette's syndrome 397
Gingivitis 37b
Glabellar tap reflexes 346, 347f, 347
Glanzmann's disease 121b
Glaucoma 84, 84b, 88t, 95, 97b, 100, 353t, 354
acute 90
Glenohumeral arthritis 435
Glenohumeral joint 448
Glisson's capsule 25
Globulins 304
Glomerular diseases 38t
acute 309
Glomerular filtration 294, 310
Glomerulonephritis 39t, 177, 303, 308b, 309
Glomus jugulare tumour 372t
Glossitis 23b, 23t
Glucoronyl transferase 307
Glucosuria 306
alimentary 306
renal 306
Glycosuria 308t, 506
Goitre 133, 511, 519t, 522
causes of 133b
hashimoto 523t
simple diffuse 523t
WHO grading of 133b
Gonadal axis 515
Gonadotropin deficiency 526t
Gonadotropin releasing hormone 526t
Gonococcal arthritis 18t, 435t
Gonococcal urethritis 315f
Gonorrhoea 298, 299b
Goodpasture's syndrome 30t
Gordon's reflex 388b
Gout 50b, 439b
Gouty tophi 439b
Gower's sign 375f, 515t
Gradenigo's syndrome 340t
Granulomatous disease 47t
Graphaesthesia 402
Grasp reflex 346f
Grasping and avoiding reflexes 346
Grave's disease 46, 51, 87, 133, 507t, 510, 511, 519, 519b
Gray matter 325
abnormalities of 275
examination of 273
Growth axis 516
Guillain-Barre syndrome 32, 366t, 371
Gustatory hyperhidrosis 17t
Gynaecomastia 17t, 25, 44b, 48, 54t, 140f, 139, 512, 513f, 519t
causes of 49t, 140t
Haemangioblastomas 301
Haemangiomas 250
Haemarthrosis 36b, 427, 476, 478t
Haematemesis 7, 8t, 14, 14t, 22, 25b, 26t, 30b, 37, 247b, 248
Haematological case, investigations for 481487
Haematological disorders, oral manifestations of 479b
Haematomas 478t
Haematuria 8t, 16, 37, 37b, 38, 39, 297, 302, 303, 305, 306, 306f, 309
causes of 39t
Haemochromatosis 47t, 70, 70b, 73t
Haemodialysis 300
Haemoglobin 305, 502, 536
Haemoglobinopathies 471
Haemoglobinuria 8t, 37b, 38, 39, 305, 306
Haemolysis 300, 306
Haemophilia 7, 15t, 37b, 121b, 154
Haemophilia A 9t
Haemophilia B 9t
Haemoptysis 7, 14t, 15t, 27, 28b, 29f, 29, 30, 30b, 32, 33, 36t, 37, 211, 216b, 238
causes of 30t
Haemorrhage 6b, 101t
Haemostasis 39t
primary 36
secondary 36, 478t
Haemothorax 217t
Hair 77
abnormalities of 80
types of 77
Half and half syndrome 301, 302f
Halitosis 53, 53b, 247b
Hallucinations 345
Hand deformities, analysis of 152t
Hands 144, 452
examination of 144
Hashimoto's disease 133, 134f, 134b
Hashimoto's thyroiditis 133, 507t, 510, 511, 522
Hay fever 18t
Head 62
Headaches 40, 62, 64
classification of 63t
primary 63t
secondary 63t
Hearing, assessment of 117
ausculation of 177f, 177
surface anatomy 177
Heart burn 19b, 21, 247b
Heart failure
chronic 33t
radiographic findings 193
Heart sounds 182, 183
abnormalities of 183
first heart abnormalities 183, 184b
S1 181
S2 181
S3 181
S4 181
second heart sound abnormalities 183, 184t
splitting 184, 185t
Heat coagulation method 304
Heaves 180
Heberden's nodes 151b
Hemarthrosis 154
Hematochezia 20
Hemiballismus 396
Hemifacial spasms 364
Hemiparesis 337t, 374b
Hemiplegia 31t, 144b, 177, 373t, 374b
contralateral 329, 330b
ipsilateral 329, 330b
Hemothorax 227
Henöch-Schönlein purpura 37b
Hepatic encephalopathy 248b, 301
Hepatic failure 60t, 416, 418t, 423b
Hepatic flexor of colon 267b
Hepatic venous pulsation 178
Hepatitis 6, 11f, 19f, 20t, 258b, 266, 299b, 300
chronic active 26t
drug induced 8t, 26t
Hepatitis A 22t
Hepatitis B 6, 26t
Hepatitis B core antigen and antibody 286
Hepatitis C virus antibody 287
Hepatitis D-antigen and antibody 287
Hepatitis E virus antibody 287
Hepatitis infective 307
Hepatobiliary diseases 19
Hepatobiliary system 248
investigations of 282
symptoms of 248b
Hepatomegaly 19, 157b, 248b, 418t
Hepatosplenomegaly 475
Herberdon's nodes 151f
Hereditary spherocytosis 20t
Hernia 20t, 255, 275
femoral 256f, 255
differential diagnosis of 275
incisional scar 255f, 255
inguinal 255, 256f, 256, 273
differential diagnosis of 275
umbilicus 255
Herpes keratitis 85b
Herpes simplex infection 90
Herpes simplex virus (HSV) 533b
Herpes zoster 80t, 124, 342
Herpes zoster ophthalmicus 85b
Herpetic vesicular eruptions 220b
Heubner's artery 334
Hiatus hernia 23b, 55t, 441b
Hip 456
Hip disease, symptoms of 456
Hip joint, examination of 456
Hippel-Lindau disease 298
Hirschsprung's disease 24t
Hirsutism 17t, 18, 44b, 49, 81
causes of 82b
differential diagnosis of 82t
HIV 6, 11f, 68, 80t, 299, 300, 491
HOCM 183
Hodgkin's disease 130, 131, 132, 475
Hoffman's sign 378, 384f
Hoffman's syndrome 45b
Holmes-Adie pupil 95
Holter monitoring 191
Homan's sign 207, 208f
Homonymous hemianopia 353t
Hormones, functions of 505
Horner's syndrome 83, 87, 88b, 89, 89t, 94, 95, 200b, 218, 357t, 371, 421f
Human chorionic gonadotrophin 49t
Humidifier fever 217t
Huntington's disease 7
Hydatid thrill 272
Hydrocephalus 22t, 62, 64b, 101t, 359b, 416
congenital 64f
Hydrocoele 317t, 386
Hydronephrosis 20t
Hydropneumothorax 229, 233, 223b
Hyperaesthesia 44b, 332
Hyperalgesia 44b, 332
Hyperbilirubinaemia 25, 307
conjugated 90
unconjugated 90
Hypercalcaemia 6b, 24t, 38t, 43, 45, 474
Hypercalcaemic crisis 20t
Hypercholesterolaemia 157b, 200b, 439b
Hyperglycaemia 84, 506
Hyperkalaemia 43t, 59b
Hyperkeratosis 145b
Hyperkinesis 519t
Hyperlipidaemia 7, 16t, 20t, 198, 304, 479b, 509, 510
Hypermagnesaemia 59b
Hyperparathyroidism 17t, 18, 22t, 45b, 150, 152t, 297f, 301, 438, 506
Hyperpathia 44b, 332
Hyperphosphataemia 297
Hyperpigmentation 70
causes of 72b
Hyperprolactinaemia 47t, 139, 300, 506, 514t
Hyper-resonance 229, 254
Hypersplenism 35, 37b
Hypertension 6, 7, 10f, 11b, 16t, 37, 55t, 59b, 121b, 192, 198, 297, 298, 300, 300b, 309, 418t
cirrhotic 8t
classification of 60b
JNC VIII classification of 172b
pulmonary 183, 184t
systemic 26, 184t
systolic 169
Hypertensive crisis 84b
Hypertensive encephalopathy 41t, 416
Hypertensive retinopathy 102b, 102f, 102, 301
Hyperthermia 60
Hyperthyroidism 17t, 27, 43b, 45, 45b, 49t, 50, 56, 59b, 80t, 150, 394t, 489t, 507t, 509
Hypertonia 375
Hypertrichosis 82, 524t
Hypertrophic cardiomyopathy (HCM) 41t, 164, 164t, 165t, 170t, 180, 184, 187
Hypertrophic osteoarthropathy 435t
Hyperuricaemia 55t
Hyperviscosity syndromes 336t
Hypoaesthesia 44b, 332
Hypoalbuminaemia 147t, 304
Hypoaldosteronism 43b
Hypoalgesia 44b
Hypocalcaemia 295, 297
Hypochromia 483t
Hypodermis 66
Hypogammaglobulinaemia 217t
Hypogonadism 49t, 317t, 507t, 514
causes of 514t
clinical features of 514t
postpubertal 513
prepubertal 512, 513f
Hyponatraemia 43t, 416
Hypoparathyroidism 45b, 101t, 395b, 507t
Hypophosphataemia 43t
Hypopituitarism 8t, 49t, 54b, 80t, 300, 416, 506, 508, 514t, 525, 526t, 526f, 526
Hypoproteinaemia 157b, 157t, 300
Hypospadias 313
Hypotension 197, 418t
orthostatic 37t, 172
Hypothalamic-pituitary dysfunction 48
Hypothalamic-pituitary-ovarian dysfunction 48t
Hypothalamus 56, 325
Hypothermia 46, 59b, 60
causes of 60t
Hypothyroidism 17t, 24t, 45b, 46, 48t, 50b, 54b, 55t, 59b, 60t, 68b, 87, 139b, 167b, 204b, 342, 374b, 416, 495t, 508, 509, 510, 515t, 520, 522, 523
autoimmune 152t
causes of 520
goitrous 522
juvenile 54t, 522, 523f
primary 45t
subclinical 506, 520
symptoms and signs 522t
transient 520
Hypotonia 330, 375, 394
flaccid paralysis 329
Idiopathic thrombocytopenic purpura (ITP) 37b, 121b
Ileocaecal mass 267
Iliopsoas abscess 268
Illusions 345
Immobile cilia syndrome 47t
Immune complex vasculitis 177
Impaired fasting glycaemia (IFG) 526b
Impaired glucose tolerance 5t, 526b
Impedance audiology 120
Impedance plethysmography 207, 208f
Impotence 17t, 46, 47t
Infectious arthritis 50b
Infective endocarditis 11f, 166, 177, 199
Inferior vena cava obstruction 252b
Infertility 47
Inflammatory bowel disease 18t, 20
Inflammatory myositis 223b
Influenza 8t
Inguinal lymph nodes 274
Insulin test 517
Intercostals spaces, palpation 224
Internal carotid artery 334
occlusion 337
Internal jugular pulsations 173t
Internal jugular vein 172
Interossei muscles 379t
Interstitial fibrosis 217t, 223b
Interstitial lung disease 33, 29b, 224
Intervertebral disc 442
Intervertebral foramina 440
Intestinal obstruction 21
acute 19f, 24t
Intracardiac thrombus 28
Intracerebral haemorrhage 418t
Intracranial pressure, raised 65, 236
Intraluminal thrombosis 208
Intraocular tension 101
measurement of 92
Intraocular tumour 84b
Intravenous pyelography 311f, 311
Intravenous synacthen test 517
Iodine deficiency 133
Iris 92
Iritis/iridocyclitis 85b
Irritable bowel syndrome (IBS) 20b, 24t, 291t, 248, 498
Ischaemic cardiomyopathy 180
Ischemic heart disease (IHD) 10f, 55t, 161, 164, 184, 189
Isometric testing 378
Isosexual precocious puberty 512f, 513
Janeway lesion 166, 177
Jaundice 6, 7, 14t, 20, 24, 25, 28, 70b, 71f, 73, 89, 90, 90f, 165b, 248b, 420, 472t
cholestatic 26t
clinical work-up 26t
haemolytic 25, 26t, 307
hepatocellular 25
in haemophilics 26t
Jaw jerk 361, 384
Jaw, protrusion and retraction of 440
Jendrassik's manoeuvre 376, 384, 387
Jerks, abnormalities of 386t
Joffroy's sign 521f
Joint crepitus 438
Joint disease, features of 429b
Joint examination
spine 440, 441
cervical 440, 441
lumbar spine 440, 442
sacrococcygeal spines 440
thoracic 440, 441
Joint pain, assessment of 429
temporomandibular joint 440
inspection 434
palpation 435
Joints and bones, examination of the 434
Jones criteria 175, 177
Jugular veins 126, 135, 340t, 342
Jugular venous pressure 34t, 59, 157b, 172, 173, 219, 249
measurement of 174f, 174
raised 173f, 175, 175f
Jugular venous pulse 59, 172
examination of 174
waveforms 173f
Juxtaglomerular apparatus 294
Kala azar 70b, 73t
Kallmann's syndrome 49t, 54b, 54t, 69, 147t, 351, 508, 513f, 514t, 526
Kayser-Fleischer ring 90, 91f
Kennedy's disease 371
Keratinocytes 67
Keratoconjunctivitis, phlyctenular 218
Keratoconus 85
Kernig's sign 350f, 350, 351
Ketoacidosis 218b
Ketonuria 306, 307
Ketostix test 535
Kidneys 294
causes of enlargement of 264b
common abnormalities 264
congenital horseshoe 264
enlarged 264
palpation 262
left kidney 263, 263t
right kidney 263f, 263
small 264
Klebsiella rhinoscleromatis 123
Klinefelter's syndrome 47t, 49t, 54t, 140t, 317t, 508, 513, 513f, 514t
Knee jerk 384
Knee joint
movements of 461
stability test 462
Knee 459
examination of 460
Knock knees 301, 301f, 435
Kocher's test 511
Koilonychia 147, 148f, 148t, 472t
Korotkoff sounds 169, 171f, 172t
Korsakoff's syndromes 11b
Kronig's isthmus 229
Krukenberg tumour 48t
Kussmaul breathing 218b, 421
Kyphoscoliosis 32b, 221t, 444, 445f
Kyphosis 441, 444, 444f, 444t
Labrinthitis 22t, 116
Labyrinthitis Meniere's disease 119
Lacrimal apparatus, inspection of 89
Lacrimal glands 83, 86, 89
Lacrimal sac 83
Lacrimation 84
Lactate provocation test 503
Lactic acidosis 33t
Lactosuria 307
Lacunar infarct 336
Lacunar syndromes 339, 339t
Lambert-Eaton syndrome 43t
Langerhan's cells 67
Laparoscopy 290
Large bowel obstruction 269
Large intestinal obstruction 254
Laryngeal carcinoma 35t
Laryngeal oedema 33
Laryngitis 28, 218
acute 35t
Laryngopharynx 124
Laryngoscopy 243
Larynx 113
Lassitude 15t, 35, 36b
Lateral bending 445
Latissimus dorsi 381t
Laurence-Moon-Biedl syndrome 45t, 54b, 55t, 147t, 354, 508
Lead 442
Leber's hereditary optic atrophy 84b
Leber's optic atrophy 100, 353t
Left atrial enlargement 192
Left atrial myxoma 168t
Left iliac fossa, mass in 269
Left ventricular aneurysm 180
Left ventricular dilatation 192
Left ventricular failure (pulmonary) 34t
Left ventricular failure, acute 33t
Left ventricular hypertrophy 180, 180b
Leg ulceration chronic 210
Legs, examination 151
Lens 90
Lens opacity 97
Leprosy 155
acute laboratory findings in 486b
chronic laboratory findings in 487b
Leucocytosis 470, 473
Leucoerythroblastosis 483t
Leuconychia 301
Leucopenia 471
Leukaemia 35
Leukaemoid reaction 473, 473b
Leukemia 473b, 474
acute 474t
chronic 474t
Levator palpebrae 83
Lhermitte's sign 332
Lichen planus 147t
Ligaments 426
Light reflex 93f
Lipiduria 304
Livedo reticularis 204, 204b
Liver 267b
abnormalities 259
abscess 25, 220
aspiration 290
biopsy 290
disease 37b
acute 25
dullness 227
enlargement 259
mass, characteristics of 259b
palpation 258
span 227f, 227
Lobar collapse 237t
Lobar consolidation 237t
Lobar pneumonia 238
Locked-in syndrome 338t
Locomotor abnormality, screening system for 431
Locomotor disorders, examination of 431
Locomotor system 426
Long flexors, testing of 379t
Lordosis 443
Low back pain, common causes of 443b
Lower limb
muscles of 381t
reflexes 384
Lower motor neuron 366t, 370, 373
lesion 330b, 329, 406t
paralysis 366f
Lower urinary tract 308t
Lumbar lordosis 264, 432f
Lumbar region mass, differential diagnosis of 268b
Lumbricals, testing of 379t
Lung abscess 30t, 217t, 223b, 234
biopsy 244
collapse 225t, 232t
fibrosis 180b, 241t
parenchyma 244
sepsis 218
volumes 243
bronchopulmonary segments of 215f
lobes of 214
surface markings of 214f, 214
Luteinizing hormone 515b
Luthy’ sign 456
Lymph nodes 481
enlargement 249
palpation 128
axillary 128, 130f
cervical 128, 129f
epitrochlear 128, 130f
inguinal lymph nodes 130f, 130
occipital lymph nodes 128, 129f
popliteal lymph nodes 130f, 130
posterior auricular 128, 129f
preauricular 128, 129f
scalene node 128, 129f
submandibular glands 128, 129f
supraclavicular 128, 129f
acute 131, 275
chronic 131, 132t
septic 132t
tubercular 132t
Lymphadenopathy 131, 132b, 165b, 176, 475
common causes of 128t
differential diagnosis of 130132
hepatosplenomegaly 470
para-aortic 127
paratracheal 127
Lymphatic carcinomatosis 33t
Lymphatic leukaemia chronic 68b
Lymphocytes 67
Lymphocytic leukaemia chronic 132t
Lymphoedema 156, 156f, 157, 208
Lymphoid leukaemia 131
Lymphomas 35
Lymphopenia 473
Macrocephaly 64b, 64f
Macrocytosis 483t
Macrotia 116
Macula 97
Macular degeneration 84, 84b, 98
Macular flecks 301
Macular sparing 352
Magnetic resonance imaging (MRI) 409
advantages of 409
Malabsorption tests 282, 283t
Malar flush 166
Malena 7, 8t, 25b, 247b, 248b
Malignancy 30t
Malignant hypertension 101t, 102b
Mallory-Weiss syndrome 8t, 11b, 30t
Malocclusion, teeth 362
Malt worker's lung 217t
Mammary souffle 186
Maple bark stripper's lung 217t
Marasmus 57f
Marfan's syndrome 54t, 54b, 55f, 144b, 147t, 192, 250, 251, 435
Mass in abdomen, differential diagnosis of 266
Mass in right hypochondrium, differential diagnosis of 267b
Mass in the epigastrium, differential diagnosis of 267b
Massive pulmonary embolism 34t
Mast cells 67
Match-stick test 236
Maxillary sinuses 121, 123f, 123
Mayer-Rokitansky-Küster-Hauser syndrome 48t
Mccune-Albright syndrome 48t
Measles 6
Mediastinal compression 101t
Mediastinal crunch 234t
Mediastinal shift 223b, 223
Mediastinitis 30t
Mediastinoscopy 243
Medulla oblongata 326
Medullary cystic disease 298
Medullary infarct 371
Medullary sponge kidney 298
Meibomian glands 67, 83
Melanin 67
Melotia 116
Memory 345
Meniere's disease 22t, 41, 114b, 116
Meningeal irritation, signs of 350
Meninges 114
Meningioma 64b, 369b, 372t
Meningism 350t
Meningitis 63t, 101t, 236, 350t, 416, 418t, 420, 424
meningococcal 420
neoplastic 371
Meningoencephalitis 418t
Mesenteric lymphadenitis 20t
Metabolic acidosis 297, 418t, 421
Metabolic bone disease 50b
Metacarpophalangeal joints (MCPs) 152t, 428b, 453
Metallic sounds 185
Methaemoglobin 73, 74
Methaemoglobinaemia 479b
Microalbuminuria 304, 305
test for 534
Microbial tests 530
Microcytosis 483t
Microphthalmia 87
Microtia 116
Micturating cystogram 312f, 312
Micturition 16t, 38, 388
Midaxillary line 213f, 213
Midbrain 326
Midclavicular line 213f, 213
Mid-diastolic murmur 182, 183
Middle cerebral artery, syndrome of 337b, 337
Middleton manoeuvre 476
Midsternal line 213f, 213
Midsystolic clicks 184, 186f
Migraine 64b, 65, 66t, 340
principal forms of 65t
Migrainous neuralgia 362t
Milkmaid's grip 394
Millard-Gubler syndrome 338t
Millard-Gubler-Foville syndrome 357t
Milroy's disease 157b
Mirizzi's syndrome 261
Mitral regurgitation 165t, 168b, 181b, 184, 187, 195
acute 184
Mitral stenosis 23t, 30t, 165, 166, 180183, 184b, 185, 187t, 194, 369b
Mitral valve 162, 177t
prolapse 164, 164t, 165, 187t
Mixed connective tissue syndrome 43b
Molluscum contagiosum 299b
Monoarthritis 430t, 434
acute infective 437f
Mononeuritis 402
Monoplegia 177, 330b, 374b
Morton's metatarsalgia 404b
Motion sickness 22t
Motor control, hierarchy of 328f, 328
Motor neuron disease 366t, 370, 371, 397
Motor system disorders 330t
Motor system, examination of 371
Multiple endocrinal neoplasia 18t
Multiple myeloma 38t, 438
Multiple myeloma, investigations for 487b
Multiple sclerosis 41, 43t, 116, 119, 120, 340, 366t, 371, 392b, 394
Mumps 6, 52t
Murmurs 163t, 165, 177, 182, 187f, 186
benign 163
causes 187t, 186
characteristics of 163b
continuous 163, 164, 165t, 186
diastolic 163, 163t, 165, 186
early diastolic 165t, 186
ejection systolic 165t, 186
innocent characteristics 164b
late systolic 165t, 186
mid-diastolic 163, 165t, 186
midsystolic 163, 186
pansystolic 163, 165t, 186
systolic 163, 163t, 164, 164t, 165, 181, 186
types of 163
Murphy's sign 260
Muscle cramps 397, 398
Muscle disorders 406t
Muscle spasm 397
Muscle strength, testing of 377
Muscle testing 379t
Muscle tone
common abnormalities 375
testing 372
Muscle weakness 45
assessment of 374b
causes of 373t
Muscle, segmental innervation 335f
Muscles upper limb 378
Muscular dystrophy 32, 374f, 375t, 375f, 375
Muscular dystrophy-duchenne type 372
Myalgia 43b
Myasthenia gravis 23t, 32, 43t, 86b, 88b, 357t, 366t, 371
Myasthenia-myopathic syndrome 43t
Mydriatic drops 96
contraindications for 97b
Myelofibrosis 483b
Myelography 410
Myelomatosis 470, 474
symptoms and signs of 475t
Myeloproliferative disorders 476
Myocardial disease 41t
Myocardial infarction 20t, 30t, 31t, 33t, 197
acute 26, 168b, 188
Myocardial ischaemia 34t, 36t, 188
Myocardial scanning 196
Myocarditis 26, 30t, 168t, 188, 192
Myoclonus 396
aetiological classification of 396t
Myoglobin 39b, 305
Myoglobinuria 38, 39b, 306
Myokymia 397
Myopathy 45, 373t
proximal 524t
Myotonia 377f, 376
cysticercosis 374b
dystrophica 47t, 88b
Myxoedema 52t, 52f, 53b, 124b, 145b, 156, 157t, 386t
Myxoedema coma 423b
Nail dysplasia 301
Nail folds, examination of 150
Nail-Patella syndrome 147t, 301
Nails 67, 144
changes in 147t
examination of 144
method of examination 145
Nasal airway 122
Nasal disease, symptoms of 121
Nasal obstruction 121
Nasal polyps 123
Nasal sinuses, examination 122, 122f
Nasolacrimal duct 121
Nasopharynx 35t, 124, 369
Nausea 247b, 248
Neck 126135
examination 126, 350
inspection 126t
palpation 126
flexors 382t
lump in 125
lymph nodes 126, 127
cervical 127
mass examination of 128b
occipital 126
posterior auricular 126
posterior cervical 127
preauricular 126
submandibular 126
submental 127
superficial cervical 127
supraclavicular 127
tonsillar 126
muscles 382t
stiffness 236, 350f, 350, 418b, 419b, 420
Needle sharing disorders 11f
Neisseria gonorrhoeae infection 533b
Nelson's syndrome 73t
Neoplasia 20t
Nephritic syndrome acute 296, 303
Nephritis, hereditary 297
Nephrotic syndrome 52t, 53b, 157t, 296, 298, 300, 301, 304, 479b
SLE induced 301f
Nephrotoxic drugs 299b
Nerve conduction 411
Nerve root compression 443f, 446
Nervous system 325
signs of lesions in 406t
symptoms 340342
Neuralgia 63t
migrainous 362
post-zoster 362
trigeminal 362
Neurofibromatosis 73f, 73t, 439b
Neurological disorder, investigations 407
Neurological examination 405
general physical examination 342
systemic 343
Neuromuscular diseases 23b
Neuromuscular junction 330
Neurons 325
Neuropathic joint 154
Neuropathic ulcer 209t
Neuropathy, clinical features of 528t
Neuropsychiatric assessment 500
Neutropenia 471, 473, 483b
Nipple discharge 139f, 139
Nipple inversion 138
Nocturia 16t, 28, 37b, 38, 44b, 293, 297, 297f, 298
Non-ejection clicks 184
Non-Hodgkin's lymphoma 131, 132t, 475
Normal thyroid profile 516b
Nose 121123
examination 122, 122f
Nothnagel's syndrome 338t
Nystagmus 115t, 359, 394t, 422
causes 119
testing for 119
Obesity 8t, 54, 56b, 198, 507t
abdominal l56b
causes 55t
consequences 55t
Obliterative arterial disease 204
Obstetrics history 300b, 300
Obstructive emphysema 181, 227
Obstructive pulmonary disease 28
chronic 10f, 175
Obstructive ventilatory defect 240
Obturator sign 267
Occlusive peripheral arterial disease 199t
acute arterial ischaemia 199t
chronic arterial disease 199t
Occupational lung diseases 217t
Ocular fundus 96, 480
Ocular movements, testing of 94
Ocular myopathies 86b
Oculocephalic reflex 367, 422
Oculovestibular reflex 367, 422
Odynophagia 20, 22, 247b
Oedema 155157, 155f, 166, 211, 219
abdominal wall 155, 156f
ankle 155
causes of 157t
differential diagnosis of 157b
distribution of 156
localised 156
nonpitting 156, 157t
pitting 155, 157t
postural 156
sacral 155
unilateral 156
Oesinophilic lung disease 234t
Oesophageal myopathy 23t
Oesophageal spasms, diffuse 23b, 30t, 31, 441b
Oesophageal tear 30t
Oesophageal varices 37
Oesophagitis 11b, 20t, 23t, 23b
Oesophagoscopy 280
Oestradiol 515b
Oligoarthritis 50b
Oligomenorrhoea 44b, 506, 519t, 524t
Oligospermia 514t
Oliguria 38, 293, 298, 303
causes of 38t
Onychodermal angle 145
Onycholysis 147t, 519t
Opening snap 185
Ophthalmic artery 356
Ophthalmic veins 339
Ophthalmoplegia 520
internuclear 394t
Ophthalmoscopy 101
Opponens pollicis 379t
Optic atrophy 46, 98, 510
causes of 100b
Optic disc 97, 98, 100
Optic neuritis 46, 84b, 98, 102b, 353t
Optic pathways 92
Optokinetic nystagmus 353t
Orbital myositis 86b
Orchitis 49t, 140t, 317t, 318f
Organ of corti 367
Oro-facial dyskinesias 397
Oropharynx 124, 125
Orthopnoea 26, 33, 164, 219
Ortic stenosis 183
Osler's node 151b, 165b, 177
Osler-weber-rendu disease 477f, 477
Osteoarthritis 18t, 50b, 428f, 428b
Osteochondromata 429
Osteogenesis imperfecta 429, 438
Osteomalacia 45b, 508
Osteomyelitis 438
Osteoporosis 8t, 55t, 442, 442b, 444t
Otalgia 113
causes of 113b
Otitis externa 117, 362
Otitis media 113b, 114b, 117, 119
Otorrhoea 114
Ototoxic drugs 114b
Ovarian cysts 20t, 269, 321t
Ovarian neoplasm 82t
Overuse syndrome 431
Paget's disease 137t, 138, 152t, 168b, 342, 372t, 435
Pain abdomen 19, 19b
Pain chest 216b
Pallor 69, 211, 219
Palmar erythema 151, 165b, 519t
Palmomental reflexes 346
Palpation sounds 180
Palpebral conjunctiva 83, 87
Palpebral fissure 83
Palpitation 14, 15, 17t, 27
intermittent 14t
paroxysmal 14t
PANCA (perinuclear staining) 466
Pancreas, carcinoma of the head 261
Pancreatic disease 19
Pancreatic insufficiency 24t
Pancreatitis 11b, 19f, 20, 26t, 43b, 443b
acute 21t, 258b
recurrent 8t
Pancytopenia 25, 483b, 470, 9478
Panhypopituitarism 47, 48t, 54t, 509, 512
causes of 526t
Papillary muscle dysfunction 187t
Papillitis 101t, 102b
Papilloedema 84b, 98, 102b, 218, 418b, 418t
causes of 101t
optic disc in 99f, 101b
Para-abducens nucleus 355
Paradoxical resonance 228
Paraesthesia 44b, 332, 364
Paralysis 42, 42b
Paranasal sinuses 121123
Paraneoplastic syndrome 46, 392b
Paraneoplastic-myasthenic myopathic syndrome 373t
Paraphimosis 313, 314f
Paraplegia 31, 47t, 330, 336, 342, 373t, 374b
Parietal lobe dysfunction 406t
Parinaud syndrome 338t
Parkinsonism 17t, 51, 52f, 52t, 371, 394t
Paronychia 150
Parosmia 54t, 351
Parotid glands enlargement 52t
Paroxysmal nocturnal dyspnoea 26, 164
Paroxysmal nocturnal haemoglobinuria 20t, 479b
Patellar tap test 460f, 460
Patent ductus arteriosus 164, 165t, 187t, 193, 197
Patrick's test 469f, 459
Peak expiratory flow 242f, 241
Peau d'orange 137t, 138, 139f
Pectoral reflex 384
Pectus carinum 178
Pectus excavatum 178f, 178, 211, 221t
Pedal oedema 16t
Pediculosis pubis 299b
Pellagra 71
Pelvic inflammatory disease (PID) 23t, 321t
PEM 508
Pendular jerks 394
Penile discharge 20
Penis 295
abnormalities 313t
inspection 313
palpation 315
Pentagastrin test 281
Pentosuria 307
Peptic ulcer 7, 8t, 10f, 11b, 248, 258b
Percussion myokymia 229
Percussion note 259b
abnormalities of 228
method 226
rules of 226
tidal 228
Percutaneous transhepatic cholangiography 288
Perforated intestine 21t
Perianal haematoma 277
Pericardial diseases 188
Pericardial effusion 157t, 170t, 179, 194, 220, 227, 262
Pericardial knock 186
Pericardial rub 185, 186, 302
Pericarditis 20, 30t, 31t, 188, 192, 223b
Pericardium 192
Perichondritis 113b
Perimetery 354
Periodontitis 37b
Periorbital oedema 52t, 121, 211
Peripheral arterial disease 198
aneurysmal disease 198
occlusive arterial disease 198
vasospastic disorders 198
Peripheral blood film (PBF) examination 481
Peripheral nerve 326, 330b
Peripheral nerve lesions 361t
Peripheral nervous system 326
Peripheral neuropathies 330b, 373t, 397, 406t
Peripheral pitting oedema, causes of 27b
Peripheral pulses
brachial pulse 202f
carotid artery 202b
femoral artery pulsations 202f
palpation of 202
pedis artery pulsations 202f
popliteal artery pulsations 202f
posterior tibial artery 202f
Peripheral vascular disease, investigations 205
Peripheral vessels, disorders of 204
Perisplenitis 476
Peristalsis 250, 254
Peritonitis 19f, 20t, 258b
generalised 254
Peritonsillar abscess 124
Pernio syndrome, chronic 204b, 205
Persistent isolated proteinuria 297
Pertussis 53
Pes cavus 152, 153f
Petechiae 37
Petechial haemorrhages 480
Peyronie's disease 313
Phaeochromocytoma 17t, 45, 59b, 167b, 204b, 418t, 489t, 506, 509, 515t
Phagocytes 67
Phalen's manoeuvre 455
Pharyngitis 23t
Pharynx 28
Phenytoin toxicity 49t
Phimosis 313, 314f
Photodermatosis 74
Photophobia 66t, 87
Piamater 62
Pickwickian syndrome 55t
Piebaldism 70
Pigeon chest 221t
Piles 24t
Pinguecula 89
Pitting oedema 219
Pituitary adenoma 100b
Pituitary tumours 46
Platynychia 148f, 147t, 472t
Pleural aspiration 243, 244f
Pleural effusion 20t, 34t, 192, 220, 223b, 224227, 232, 232t, 237t
dullness in 228
shifting dullness 228
Pleural rubs 32b, 225, 229b, 232234, 235t, 302
Pleurisy 32, 223b
Pleuritis 31t, 32
Pleurodynia 225, 234t
Plummer-Vinson's syndrome 23t
Pneumaturia 40
Pneumoconiosis 241t
Pneumocystis carinii 473
Pneumonectomy 224
Pneumonia 25, 29b, 30, 32, 33, 34t, 35, 211, 217t, 418t
Pneumonic consolidation 232t
Pneumothorax 30t, 32, 33, 33t, 180b, 192, 220, 220b, 223b, 224227, 232t, 237t
Poikilocytosis 483t
Poland's syndrome 147t
Poliomyelitis 6, 8t, 23t, 370
Polyarthralgia, causes of 50b
Polyarthritis 50b, 176, 176b, 298
symmetric 430t
Polychondritis helix 113b
Polycystic kidney disease 298
Polycystic ovarian syndrome 82t, 322b, 507t
Polycythaemia 70b, 151b, 199, 218, 219, 220, 340b, 470, 474
Polydactyly 148f, 147b
Polydipsia 44, 44b, 298, 507t
Polymenorrhoea 17t
Polymyalgia rheumatic 43b, 428b
Polymyositis 50b, 373t
Polyphagia 298
Polyposis 150b
Polyuria 6b, 27, 37, 38, 44, 44b, 293, 297, 297f, 298, 507t
causes of 38t
nocturnal 303
Pons 326
Popliteal artery aneurysm 205t
Porphobilinogen 308f, 308, 535
Porphyria 39b, 375t
Portal hypertension 22, 25, 26t, 248b, 252b
non-cirrhotic 8t
Portal venography 289
Port-wine stain 77, 78f, 342
Positron emission tomography (PET) 468
Posterior axillary line 213f, 213
Posterior cerebral artery
syndrome 337
p1 syndrome 337, 338b
p2 syndrome 337, 338b
Posterior cranial fossa lesion 420
Postictal phenomenon 16t
Postmenopausal bleeding 300
Postnasal space, examination 123
Postphlebitic syndrome 208
Post-tussive crackles 233
Post-tussive suction 233
Postural hypotension 41t, 402
Post-zoster neuralgia 362t
Pott's disease 30t, 258b, 275, 444
Pouch of Douglas 278
Prader-Willi syndrome 45t, 55t
Prechordium examination
auscultation 177, 181, 182
auscultatory areas 177f, 181
inspection 177, 178
chest deformities 178
localised bulge 178
pulsations 178
scars 178
palpation 177, 179
percussion 177
Precocious puberty 48
Precordium, examination 177
Premorbid personality 495
Pretibial myxoedema 519t, 520
Priapism 47, 47b
Primary haemostasis 478t
Primary haemostatic defect 477
Proctitis 19f, 24
Progesterone 515b
Prognathism 54t
Prolactin 526t
Prolactinoma 523
Pronator sign 394
Proptosis 49, 84, 85b, 87, 88t, 121
Prostate 276
disorders 276
enlargement 298
palpation of 278
Prostatic carcinoma 298
Prostatitis 39t
Protein energy malnutrition (PEM) 56t
Proteinuria 302, 304, 533
aetiopathogenesis of 305
asymptomatic 305
Bence-Jones 305
consequences 304
glomerular 305
orthostatic 305
tests 304
tubular 305
Proximal interphalangeal joints (PIPS) 453
Pruritus 25, 25b, 26t, 68b, 248b
Pseudobulbar palsy 23b, 338t, 369b, 371, 372b
Pseudocushing syndrome 53b
Pseudohypopara-thyroidism 147t
Pseudomembranous colitis 23t, 24
Pseudopancreatic cyst 267b
Pseudopapilloedema 101t
Pseudoptosis 89
Psoas cold abscess 442
Psoas sign 267
Psoriasis 64, 74, 147t, 428b
Psoriatic arthritis 434
Psoriatic arthropathy 152t
Psychiatric assessment 489
investigations 502
Psychiatric history 490
Psychogenic hyperventilation 33t
Psychogenic polydipsia 44, 45t
Psychological tests 503
Psychosis 519t
Pterygium 85, 85b
Ptosis 88, 96t, 357
common causes of 88b
testing for 88
Puddle's sign 271f, 271
Pulmonary arteries 193, 194
Pulmonary consolidation 234t
Pulmonary conus 192
Pulmonary embolism 32, 33, 33t, 208, 217t
acute 59b
Pulmonary fibrosis 32b, 225, 225t, 232t
Pulmonary function tests 239, 241t
obstructive lesion 241t
restrictive lesion 241t
Pulmonary hypertension 41t, 180, 193
Pulmonary infarction 32, 225, 234t
Pulmonary oedema 29, 32b, 33, 34t, 166, 418t
acute 27b
Pulmonary oligaemia 193
Pulmonary rales 418t
Pulmonary regurgitation 165, 186b, 187t
Pulmonary stenosis 41t, 165t, 180, 184, 186b
Pulmonary tuberculosis 229, 239
chronic 232t
Pulmonary valves 162, 177t
Pulmonary valvular stenosis 187t
Pulse deficit 59, 166
Pulsus alternans 168
Pulsus paradoxus 168, 169
Pupil 83, 92, 96
common abnormality of 93, 94t, 94f
constriction 93, 95t
dilatation 93, 95t
Pupillary reflexes 352
Purpura 37, 480f, 480
Pursed-lip breathing 219f, 218, 223
Pyelonephritis 20, 38t, 309
Pyloric obstruction 254
Pyloric stenosis 254
Pyoderma gangrenosum 69t, 70f, 248
Pyonephrosis 20t
Pyopneumothorax 223b, 225t
Pyuria 298
Quadriplegia 330b, 373t
Quervain's tenosynovitis 152t
Radial pulse 167f
Radiocarpal joint 453
Radionuclide scanning 196
Radioulnar joint 453
Rapid breathing 218b
Rapid left ventricular filling 184
RAS 416
Raynaud's phenomenon 151, 165, 200b, 204f, 204, 435t
Reagent strips 307
Rectal bleeding 247b
Rectal prolapse 276, 277
Rectum 276
Recurrent laryngeal nerve palsy 200b
Reducing sugars, tests for 307
Reflex sympathetic dystrophy 204b, 205
anal 388
bulbocavernosus 388
ciliospinal 405
corneal 388
cough 388
cremasteric 386
mass 389
palatal 388
pilomotor 405
plantar 387, 387b
scapular 388
superficial 386
superficial abdominal 386
tendon 385
Refraction test 100
Refractive errors 84
astigmatism 97
hypermetropia 97
myopia 97
Reifenstein's syndrome 140t
Reiter's syndrome 18t, 50b, 428f, 434
Renal angiogram 312
Renal artery stenosis 38t, 302
Renal biopsy 312
Renal bone disease 298
Renal clearance 310
Renal colic 38b, 258b, 298
Renal disease 7
investigations 302312
Renal failure 6b, 298, 309, 423b
acute 296
chronic 73t, 295, 297, 416, 508
severe 310
Renal functions 294
Renal infarction 20t
Renal oedema 52t
Renal osteodystrophy 297
Renal rickets 301
Renal transplant 300
Renal tubular defects 297
Renin-angiotensin-aldosterone cascade 304
Renin-angiotensin-aldosterone system 294
Reptile tongue 394
Resonance 225
Respiratory disease
investigation 238244
chest X-ray 239
computed tomography 239
cytological examination 239
microbial examination 239
routine haematological 238
routine sputum examination 238
serological tests 239
skin tests 239
physical signs 237t
skin lesions in 220b
Respiratory function test 236
Respiratory muscle dysfunction 32
Respiratory muscle paralysis 32b
Respiratory reflex 402
Respiratory sinus infection 7
Respiratory symptoms 28
Respiratory system 212
general physical examination 218
surface anatomy of 212f
Respiratory tract, common symptoms 216b
Restrictive lung disease 218b
Restrictive ventilatory defect 240
Retina 83, 92
Retinal atrophy 98
Retinal detachment 84b
Retinal haemorrhages 98
causes of 102
Retinal vascular thrombosis 301
Retinal vein occlusion 84b, 100
Retinitis 102b
Retinitis pigmentosa 84b
Retinopathy 100, 510
Retrobulbar neuritis 98
Retroperitoneal fibrosis 295
Retropharyngeal abscess 124
Retrosternal chest 247b
Reversible ischaemic neurological deficit 16t
Rheumatic arthritis 152t, 435t
Rheumatic carditis 176
Rheumatic diseases 428b, 454t
extra-articular manifestations 430t
symptoms of 49
Rheumatic disorders 427, 435
major symptoms of 427b
Rheumatic fever 6, 8t, 18t, 50b, 161, 175, 439b
acute 6
criteria 176b
Rheumatic heart disease 6, 168t
Rheumatic nodules 439b
Rheumatic symptoms, common 49b
Rheumatic valvular disease 6
Rheumatism 8t
soft tissue 429
symptoms and signs of 429t
Rheumatoid arthritis 18t, 43b, 50b, 69t, 90, 144b, 152t, 176, 428b, 428f, 434, 435, 438f, 444b
boutonniere 435
swan-neck 435
ulnar deviation of hand 435
Z-shape deformities 435
Rheumatoid factor 465
Rheumatoid nodules 151b
Rhinitis 28, 35, 121, 121b, 122
Rhinorrhoea 121
Rhonchi 233
Rickets 508
Rickety rosary 301
Riedel's thyroiditis 511
Right atrial enlargement 192
Right bundle branch block 184
Right ventricular dilatation 174, 192
Right ventricular failure 193, 219, 219t
Right ventricular hypertrophy 180, 192
Rigidity 377b
hysterical 376
paratonic 376
reflex 376
Ringed sideroblast 484f
Rinne test 118
Romberg's sign 120, 332
Romberg's test 391
Rome criteria
for IBS 248
Rossolimo's sign 388b
Rotation 445
Roth's spot 177
Rothera's test 307, 535
Rovsing's sign 266
Rubella 6, 8t
Ruptured ectopic gestation 258b
Ruptured tubal pregnancy 321t
Russell-silver syndrome 48t
S1, first heat sound 183
S2, second heart sound 183
S3, third heart sound 183
Sacroiliac joints 445, 448
Sacrum 440
Saddle embolism 200b
Salicylsulphonic acid test 534
Salivary glands 126
Salmonellosis 299b
Salpingitis 20, 48t, 258b
acute 21t
Sarcoidosis 69t, 89, 132b, 239, 241t, 353, 366t, 435t
Scabies 68b, 299b, 313
Scalp 62
Scalp examination 64
Scaphoid abdomen 254
Scapular line 213f, 213
Schamroth's window test 146
Scheuermann's disease 442b
Schirmer's test 364
Schistosomiasis 39t
Schmidt's syndrome 46
Sciatic nerve roots compression 445
Sclera 86, 89
Scleritis 90
Sclerodactyly 147b, 149f
Scleroderma 43b, 50b, 152t, 157t, 200b
Scoliosis 192, 234, 444
severe 54b
Scrofuloderma 220b
Scrotal hernia 317t
Scrotal swelling, differential diagnosis of 275
Scrotum 295
abnormalties of 317t, 318f
inspection 315
palpation 315
Scurvy 37b
Sebaceous glands 67
Seborrhoeic dermatitis 64
Seborrhoeic warts 250
Secondary sexual characters 513
Seehan's syndrome 8t
Semen analysis 536
indications for 536
Semilunar valves 162
Sensations 398402
Sensory ataxia 44b
Sensory pathways 330
Sensory system, examination of 333
Sentinal pile 277
Septic embolisation 177
Serological test 530
Serratus anterior 381t
Serum lipids 286
Serum proteins
albumin 58, 285
albumin and globulins ratio 285
globulin 285
Serum transferrin 58
Sex hormones 515b
Sexually transmitted diseases 298, 299
causative agents 299b
SGOT 284
SGPT 284
Shallow breathing 218b
Shapiro's syndrome 60t
Sheehan's syndrome 512, 526t
Shigellosis 299b
Short acth stimulation test 517
Shoulder examination 449
Sick sinus syndrome 59b, 167b
Sickle cell disease 47t, 102, 298, 514t
Sighing respiration 218b
Silicosis 217t
Simple diffuse goitre 522
Single nerve lesion 402
symptoms and signs of 404t
Single photon emission tomography (SPECT) 196f, 196
Sinus of Valsalva 164, 187t
Sinus rhythm 167
Sinus tachycardia 34t
Sinus tenderness, palpation for 123
Sinusitis 121b, 123
Situs inversus 228
Sjögren's syndrome 46, 85b, 89, 90, 435t
Skeletomuscular disorders, diagnostic tests in 465b
Skin lesion 76t
Skin pigmentation, abnormalities of 70t, 69
Skin 66
associated lymphoid tissue (SALT) 67
examination 69
functions of the 67
Skodaic resonance 229
abnormalities 62, 64b
examination 64
X-rays 407
SLE 43b, 73t, 90, 204, 300, 428b, 435t, 479b, 485
Sleep apnoea syndrome 55t, 489t
Snake bite 88b, 357t
Sneezing 122
Snellen's chart 91
Snout and sucking reflex 346
Somnolence 16t
Sore throat 124
Sour eructation 22
Spastic paralysis 373t
Spasticity 377b
Spermatic cord 316
Spermatocoele 317t, 318f
Spherocytosis 472t
Spider angiomata 251
Spinal artery syndromes, features of 339
Spinal canal stenosis 442
Spinal cord and spinal artery syndromes 339
Spinal cord 326
compression 442
regions 326f, 326
Spinal dermatomes 334
Spinal myotomes 334
Spinal nerves 62
Spinal reflex arc 330, 331f
common abnormalities related to 444b
examination 443
inspection 443
palpation 444
lumbar spine 445
extension 445
flexion 445
rotation 445
Spinomuscular dystrophy 397
Spinothalamic tracts 331, 406t
Spinous process 440
Spirometry 239
common abnormality 262
examination 476
palpation 261
Splenic disease 19
Splenic dullness 228
percussion 272
Splenomegaly 262, 475, 476
Splinter haemorrhages 147t, 165b, 166f, 166, 177, 301, 435t
Splitting of sound 182
Spondylolisthesis 445
Sprengel's deformity 444t
Sputum 28, 216b
characteristics 29t
Squint 86, 95t, 359
non paralytic 94, 95t, 96t
paralytic 94, 95t, 96t
Stapedius reflex 363
Status epilepticus 416
Steatorrhoea 24, 54b, 57
Stereognosis 402
Sternal angle 212
Sternoclavicular joint 449
Sternomastoid muscles 174, 219
Steroid-induced myopathy 45b
Stomach 267b
Stomatitis 23b, 23t
Strabismus 94
Straight leg raising test 447f, 447
Stransky's sign 388b
Stress radionuclide scanning 196
Stridor 28b, 33, 35t, 36t, 124, 216b, 218, 233, 234t
Stroke 7, 119, 353t
causes of 336t, 336
haemorrhagic 336
ischaemic 336
small vessel 336
Sturge-weber syndrome 78f
Subarachnoid haemorrhage 420, 424
Subarachnoid space 326
Subclavian artery aneurysm 204
Subclavian pulsations 126
Subclavian steal syndrome 203
Subclavian vein occlusion 200b
Subconjunctival haemorrhage 85b, 177
Subcutaneous nodules 176, 438, 439b
Subdural haematoma 8t, 101t, 410, 418t
Subhyloid haemorrhages 99
Submandibular duct 125
Submandibular glands 363
Subperichondrial haematoma 113b
Subphrenic abscess 25, 267b
Substantia nigra 325
Subthalamic nuclei 325
Succussion splash 233, 273
Sudomotor function 405
Superficial reflexes 330t
Superficial thrombophlebitis 206
Superficial venous thrombophlebitis 208f, 208
Superior mesenteric artery thrombosis 258b
Superior sagittal sinus 339
Superior vena cava 192, 193
obstruction 175, 193, 219, 219t, 220b
Suppurative lung disease 54b
Suppurative otitis media acute 113b, 114
Suppurative pneumonia chronic 232t
Supraclavicular nodes 137t
Supraventricular tachycardia 27, 167b, 173
Surgical scars 251b
Sweat glands 67
Syncope 27, 28, 41, 42t
causes of 41t
Syndactyly 147b, 148f
Synovial fluid examination 466
Synovial joint 426f, 426
Synovitis 49, 49b, 428b, 434
Syphilis 80t, 193, 299b
Syphilitic chancre 313t
Syringomyelia 357t, 370, 397
Systemic lupus erythematosus 80, 302
Systemic sclerosis 23t, 435t
T cells 67
T3 133, 516b, 520
T4 133, 516b, 520
Tabes dorsalis 155, 357t, 392b
Tabes mesenterica 268b
Tachycardia 46, 59b, 167b, 184b
arrhythmic 167b
sinus 167b
Tachypnoea, causes of 60b
Tactile vocal fremitus 224
abnormalities 225t
Takayasu's arteritis 153, 199
Takayasu's syndrome 336t
Tamm-horsfall mucoproteins 304
Tandem walking 391
Tarsal tunnel syndrome 404b
Teitz syndrome 30t, 31t
Telangiectasias 480f, 480
Telogen effluvium 80t
Temperature intolerance 45
Temporal arteritis 199
Temporomandibular arthritis 113b, 362t, 362
Temporomandibular joints 113
Tendinitis 50b
Tendon jerks, abnormalities of 386
Tendon reflexes 378
Tendon sheath crepitus 438
Tendons 426
Tension pneumothorax 232t
Tensor tympani muscles 360
Terminal bronchioles 213
Terry's nails 147t, 149f
Testes 317, 318f
inspection of 513
palpation 315
small 317t, 318f
tumour of 317t, 318f
Testicular atrophy 25
Testosterone 515b
Tetanus 6
Thalamic haemorrhage 421f
Thalamic syndrome 338b
Thalamus 325
Thalassaemia 472t, 479
Thermoanaesthesia 332
Thin basement membrane (TBM) disease 297
Thirst 6b
Thomas' test 458
Thoracic arch aneurysm 200b
Thoracic outlet syndrome 200b
Thrills 181b, 181
diastolic 181f, 181b
systolic 181b
Throat swabs 532
Throat, examination of 124, 249
Thromboangiitis obliterans 199, 208
Thromboasthenia 37b, 476
Thrombocytopenia 25, 36, 476, 477, 483b
Thrombocytopenic purpura 478f, 480f, 480
Thromboembolism 165, 485
recurrent 234t
Thrombophlebitis 11f, 206
Thrombosis 470, 477
arterial and venous 477
deep vein 477
Thrombotic disorders 479b
Thumb abduction test 455
Thyroglobulin 133
Thyroid axis 516
Thyroid disease 300b, 506
Thyroid hormones 133
functions of 133
Thyroid gland 7, 126, 132134
auscultation of 511
examination of 134
inspection of 510
palpation of 511, 511f, 511b
Thyroiditis 133b, 507t, 519b
Thyromegaly 510
Thyrotoxic crisis 22t
Thyrotoxic heart disease 59b
Thyrotoxicosis 32, 140t, 166, 167b, 168t, 180, 394t, 509, 510, 519, 519t, 519f
causes of 519b
clinical manifestations of 519t
differential diagnosis of 520, 522t
eye signs in 520
TIAS 41, 43t
TICS 40b
Tinea capitis 80t
Tinel's sign 455
Tinnitus 114, 116, 489b
Todd's paralysis 16t
Tonsillitis 131
Torticollis 40b, 127f, 444b
Toxic optic atrophy 84b
Trachea 126, 134, 223
examination 134
Tracheal obstruction 222
Tracheal tug 219
Tracheitis 30t
Tracheobronchial tree 229
Tracheobronchitis 30, 32b, 53
Trail's sign 126, 134, 223
Transient hemiparesis 65
Transient ischaemic attacks 84b, 336
Transient ischaemic attacks, features of 337t
Transillumination 316f, 316
Transitory ischaemic attacks 16t
Trapezius muscles 368, 444t
Trapezoid nuclei 367
Traube's area of resonance 228
Traumatic flail chest 221t
Tremors 392
characteristics and causes of common 394t
classification of 394b
Trendelenburg test 209f, 209, 457f, 457
TRH stimulation test 503
Triceps 380t
Trichomonas spp. 533b
Trichomoniasis 299b
Tricuspid regurgitation 165, 174, 187t
Tricuspid stenosis 175, 187t
Tricuspid valves 162, 163, 174, 177t
Trigeminal nerve lesion 361
Trigeminal neuralgia 362
differential diagnosis of 362t
Trophic ulcers 209t
Tropical pulmonary eosinophilia 233
Trousseau's sign 397
Truncal ataxia 329, 390
Trunk, muscles of 381t
TSH 516b, 520
TSH deficiency 526t
TSH receptors-binding antibodies (TRABs) 520
Tubercular laryngitis 35t
Tuberculin test 239
Tuberculosis 6, 8t, 18t, 19, 30t, 35, 49t, 69t, 130, 132b, 216, 217t, 218220, 220b, 236, 336t, 525, 526t
Tuberous sclerosis 298
Turner's syndrome 48t, 54b, 54t, 126f, 147t, 508
Ulcerative colitis 24, 24t, 69t, 150b, 248
Ulnar deviation 144b
Umbilical hernia 268b
Umbilicus 251
Unconsciousness 415
Upper limb reflexes
biceps 383f, 378
finger flexion 384f, 378
supinator 383f, 378
triceps 383f, 378
Upper motor neuron 366, 373t
lesion 329, 330b, 406t
paralysis 366f, 371
Uraemia 33t, 37b, 68b, 218b, 296, 300, 301
Urea 310
Ureteric colic 8t
Ureteritis 20t
Ureters 295
Urethral caruncle 318
Urethral stricture 39t, 298
Urethritis 18t, 39t, 528b
Uric acid stones 298
Urinary abnormalities, asymptomatic 297
Urinary bladder 295
disorders 38b
palpation 264
Urinary incontinence 39
causes of 39t
Urinary system 294f, 294295
symptoms and signs 296b
Urinary tract infection 8t, 297
Urinary tract obstruction 298
Urine colour, abnormalities of 303b
Urine culture 531
chemical analysis of 533
crystals 309
Urine examination 302310
granular 309
hyaline 309
microscopic examination 308
for culture 309
S. mansoni 309
Schistosoma haematobium 309
Trichomonas vaginalis 309
mid-stream sample of 310b
sugar tests for 534
tests 282
Urobilin 307, 308
Urobilinogen 307, 308, 535
Urobilinogenuria 307
Urochrome 303
Uroerythrin 303
Urticaria 68b
Uterine fibroids 320
Uterine prolapse 317, 320
bimanual palpation 319f, 320
retroversion 321
Vaginal examination 317
Valsalva manoeuvre 66, 164t, 405
Valvular heart disease 26, 59b, 192, 203
chronic 177
Valvular stenosis 168b
Varicocele 317t, 318f
Varicose veins 55t, 206, 208
Vas deferens 47t, 316
Vascular bruits 273
Vascular disease 200, 200b
Vascular occlusion 205
Vasculitis 205, 302, 480
Vasopressin test 44
Vasospastic disorders 204
Vegetative state 419b
Venereal warts 313t
Venipuncture 529f, 529
Venous disease, cardinal symptoms of 206b
Venous hum 186, 273
Venous insufficiency chronic 206, 208, 209t, 210
Venous system, examination 206
Ventilation perfusion scan 243
Ventricular aneurysms 192, 196
Ventricular ectopics 27, 167
Ventricular hypertrophy 34, 36t, 188
Ventricular septal defect 165, 181b, 187t
Ventricular systole 174
Ventricular tachycardia 27, 167b, 173
Vertebral artery aneurysm 371
Vertebral foramine 440
Vertebral line 213f, 213
Vertebrobasilar arterial insufficiency 41t, 203
Vertebrobasilar artery syndrome 338
Vertigo 40, 115
benign paroxysmal positional 115, 116t
central positional 115, 116t
common causes of 115b
organic 116
psychogenic 116
Vestibular function
abnormalities of 119
assessment of 119
Vestibule 121
Vestibulitis 122
Video-telemetry EEG 502
Vincent's infection 37b
Viral exanthems 8t
Viral hepatitis, serological test for 286
Virchow's gland 131
Virchow's node 128
Virilisation 82t
Viscera palpation 258
Visionfield 352
Visual acuity 91
Visual evoked potential (VEP) 101, 411
Visual field 92
Visual field loss, clinical manifestations of 353t
Visual fixation 119
Visual function, testing of 91
Visual loss 84b
Visual pathways 352f
A 89, 101t
B12 17t
deficiency 57
D 67
deficiency 57
K deficiency 37b
Vitiligo 17t, 70, 70b
Vitreous body 83
Vitreous degeneration 84b
Vitreous haemorrhage 99, 102b
Vocal cord paralysis (recurrent laryngeal nerve paralysis) 218
Vocal fremitus 225b, 225f, 225
Vocal resonance 232
Volvulus 20t
Vomiting 19b, 22, 25b
common causes 22t
Von Willebrand's disease 37b, 121b, 477
Von Hippel-Lindau disease 301
VSD 193, 195, 197
Waist-hip ratio 55
Wallenberg syndrome 338t
Wartenberg's sign 378, 384f
Water deprivation test 517
WDHA syndrome 24t
Weber's syndrome 338, 357t
Weber's test 119, 367f, 367
Wegener's granulomatosis 342
Weight changes 53
Weight gain 45
Weight loss 56
Wernicke's area 347
Wheezes 7, 28b, 32, 33, 34t, 211, 216b, 225, 229b, 233, 234t
Whispering pectoriloquy 232
White matter 325
Whooping cough 6, 217t
Wilson's disease 90, 147t, 298, 394t
Wolff-Parkinson-White (WPW) syndrome 168t
Wrist 452
Wrist drop 144b
Wrist joint 454
Xanthelasmas 87, 200b, 510
Xanthomatosis 508t
Xiphisternum 254
Zollinger-Ellison syndrome 20, 22, 24t
Chapter Notes

Save Clear

1History Taking and Physical Examination
Unit I: History Taking and Review of System
  1. History Taking
  2. Analysis of Systemic Symptoms
Unit II: Physical Examination
  1. General Physical Examination
  2. The Head, Scalp, Skin and Hair
  3. The Eyes
  4. The Mouth and the Pharynx
  5. The Ear, Nose, Sinuses and Throat
  6. The Neck
  7. The Breast and the Axillae
  8. The Extremities

Unit I: History Taking and Review of System: History TakingCHAPTER 1

A student while posted in medicine has to learn the clinical medicine with following aims:
  • One should learn the art of taking a detailed informative history. History taking is an important aspect of medicine.
  • One has to know the method of detailed physical examination to be carried out. Both the important positive and negative physical signs are to be noted so as to reach some conclusion at the end of examination.
  • The exact terminology used in medicine has to be followed. Terminology based on science is the foundation for the solution to many clinical problems.
  • The practice of medicine combines both science and art. The dazzling advances in biochemical methodology and in biophysical imaging techniques that allow access to the remotest recesses of the body are the products of science. So, too are the therapeutic manoeuvres which increasingly are major products of medical science. One has to learn the skill in the most sophisticated application of laboratory technology or use of the latest therapeutic modality.
  • The ability to extract items of crucial significance from a mass of contradictory physical signs and from the printouts of laboratory data, when a clinical sign is worth pursuing or when to dismiss it as ‘red herring’ and to estimate in any given patient whether a proposed treatment entails a greater risk than the disease are all involved in the ‘decision-making’. This combination of medical knowledge, intuition and judgement is termed the art of medicine, which one has to learn.
  • The patient-doctor relationship: It may be emphasised that students/physicians need to approach patients not as ‘cases’ or ‘diseases’ but as ‘individuals’ whose problems/symptoms are to be heard sympathetically. Most patients are anxious and frightened. Often, they go to extreme ends to convince themselves that illness does not exist or unconsciously develop false belief or perception about benign disease as life threatening illness. Some patients may use illness to gain attention, or to serve as a crutch to extricate themselves from an emotionally stressful situation; some even feign physical illness. Without this knowledge, it is difficult for the physicians to gain rapport with the patient or to develop insight into the patient's illness. The patient-doctor relationship must be based on thorough knowledge of the patient and on the mutual trust and the ability to communicate with one another. A strong personal relationship with the patient is essential in order to sustain the patient during stressful situation.
The Skills
The written history of a patient should contain all the facts of medical significance in the life of the patient. The history should be recorded in a chronological order. The recent events should be given most attention. A problem-oriented approach should be adopted while recording the history; the problems that are clinically dominant should be listed first. Ideally, patient should be allowed to narrate his/her history in his/her own way and language without any interruption. However, few patients have sufficient power of observation or recall to give a history without some guidance from the physician. A physician/student must be careful not to suggest the answers to the questions being posed. A physician/student should hear the history with patience, often a symptom which has concerned a patient most may have little significance, while an apparently minor complaint may be of considerable importance. Therefore, the physician must be constantly alert to the possibility that any event narrated by the patient, however, trivial or apparently remote, may be the key to the solution of the medical problem.
An informative history is more significant than orderly recorded symptoms. Something is always gained by listening to the patient and noting the way in which he/she expresses the symptoms. Inflictions of voice, facial expression and attitude may betray important clues to the meaning of the symptoms to the patients. In listening to the history, physician/student discovers not only something about the disease but also something about the patient.
Unless patient is known, clinicians should introduce themselves by name and explain their position. If appropriate, the patient identity must be confirmed along with that of any accompanying person. The patient may be interviewed alone or in the presence of an accompanying person. This may allay anxiety and may be necessary in some situations such as memory impairment and language difficulty or an unconscious patient. The accompanying person or third person or a family member may be involved during discussion after the clinical examination as this may improve patient's subsequent understanding of the information given by the doctor.
Interview Technique
It includes:
  • What to ask about? It is useful to think about questions to be asked which are multilayered. A positive response leads to further questioning; whereas negative response moves the clinician on to the next question.
  • How to ask? The patient needs to understand what is being said. Generally speaking, technical words should be avoided. The public is becoming increasingly aware of medical terms or medical matters through the internet and mass media, but this does not necessarily mean they understand the terms, therefore, certain terms having different meanings may be clarified if used by the patient.
There are two main types of enquires—open (how, what and why type of questions) and closed (who, when, where types of questions). Examples of inquiries and there purpose is depicted in the Box 1.
Pitfalls in History Taking
With experience, the following pitfalls in history—taking have become apparent.
  • What the patients relate for the most part consists of subjective phenomenon and they obviously differ widely in their responses to the same stimuli and in their interpretation. Their attitude is variably influenced by fear of disability and death and by concern over the consequence of their illness to their families.
  • Accuracy of the history is affected by language or sociological barriers.
  • History is also influenced by intellectual powers which interfere with recall. This is the reason that, sometimes narration by the patient may be difficult due to failing intellectual powers, hence, in such a situation it is narrated by the accompanying person which, in itself, may not be true representation of patient's symptoms.
  • History taking in unconscious patient is difficult. It is difficult to collect factual data and physician is forced to proceed with objective evidence of the disease.
It is in obtaining the history that the physician's skill, knowledge and experience are most helpful.
Parts of History Taking/Recording
It consists of the following parts:
  • Name, age, sex, father's name, marital status, full address, occupation, socio-economic status.
  • Chief complaints.
  • History of present illness.
  • Past history of illness.
  • Treatment (drug) history.
  • Family history.
  • Personal history:
    • – Occupational or socio-economic history.
    • – Dietary history.
    • – Menstrual history in females.
Chief Complaint(s)
Ask the patient regarding the main complaint for which he/she is seeking medical consultation. Most of the patients have mainly one or two complaints which are recorded in chronological order easily (see Box 2) but sometimes because of nervousness, anxiety, apprehension and fear, they may exaggerate the symptoms to gain sympathy and make a list of complaints that are recorded in an order in which the most troubling complaint becomes the presenting complaint.
The question of duration of a complaint is difficult especially in old people and in uneducated people. Majority of patients do not remember the exact duration of complaints. In such a situation, approximate duration may be asked. The duration of complaints gives a rough idea of duration of disease whether acute, subacute or chronic and its progression. The onset of complaints may help to make the diagnosis in the absence of objective evidence. For example, to satisfy the definition of chronic bronchitis, history of intermittent cough for three months in a year for two years is sufficient for diagnosis.
How to Write the Chief Complaints?
The format is to ask the patient “what is your main complaint”? And then “when were you last in your usual state of health”. This leads to the request; please tell me what has happened to you since then. The format of chief complaint(s) in chronological order is given in the Box 2.
The History of Present Illness
Ask the patient to tell the detailed story of his/her illness from the day it started till today, giving the details of treatment, if taken. Ideally, patient should not be interrupted while narrating the history. During history, patient may tell the things or statements which are of no consequence; these should be ignored. Sometimes, patient may describe the complaints in medical terms such as they may use rheumatism for joint pains and migraine for headache. The patient here will be asked to tell what actually happens during these complaints or he/she should give full details of the symptoms. While listening to the history, a student/physician can ask the patient to give more details about that specific symptom. Sometimes, symptoms and signs appear and disappear spontaneously and one should try to confirm whether they are related to relapse or remission of the disease.
When a student/doctor has understood the story of illness, he should proceed with each main complaint turn by turn and examine it in details. The first step in history is to make sure that you and patient are talking about the same thing. Sometimes, patient may use certain words which may have many meanings or may have different interpretation. In such a situation, one should clearly ask what does it mean actually. For example, a patient may say wind in the abdomen that moves from abdomen upwards into the brain and causes headache. Ask the patient directly whether he/she means that wind does not pass down and instead it goes up and causes discomfort.
Aims of Present History
  • To keep history flowing by asking so what happened next?
  • To identify those aspects of history which are incomplete and require further questioning.
  • To pick up clues about the patient's reaction to the complaints, emotional and mental state of the patient.
Analysis of a Symptom
Perhaps the most common complaint is a pain which brings the patient to a doctor. The way in which a symptom is to be analysed is illustrated with the example of pain. Ask about the following points.
  • Site: Where is the pain? Note the way by which the patient illustrates the site, either he/she will use his/her finger or spreads his/her hand over the chest.
  • Radiation: Is it static or moves from one place to another?
  • Severity: How severe is it? Is it variable in severity from time to time? It depends on an individual's perception of pain. Patient may use exaggerated terms such as agonising or tearing to seek sympathy of the doctor or to overcome socio-psychological distress.
  • Timing: Note the time or any diurnal variation of symptom.
  • Occurrence or its exaggeration: Note what brings the pain. How does it get relieved? Are there any precipitating factors? Is it related to exertion? Does it occur at rest? Is there any relation to food, etc.?
  • Relief: What makes it better? Does it get relieved with the change in position? Is it relieved by food, by defaecation or by passage of wind? Cardiac pain is brought by exertion and is relieved by rest.
  • Effect of treatment: The effect of drugs may have diagnostic value.
It is, however, possible to explore other symptoms, for example, thirst, by asking the relevant questions. The enquiries to be made for thirst are given in the Box 3. This is an urge to drink water. It occurs in variety of disorders.
Similarly, other symptoms analysis may be done according to the systemic symptoms discussed under the symptoms of systemic disorders. Towards the end of present illness, besides positive complaints of the patient, one must ask certain relevant questions about symptoms which the patient has not complained. This is important from following points of view:
  • Patient may not like to include it as main complaint but that may be important for diagnosis.
  • Presence and absence of symptoms not told by the patient may help in making the diagnosis and to exclude other similar conditions.
  • Other information relevant to the symptoms may be necessary such as risk factors for coronary artery disease in a patient with chest pain or current medications in patients with syncope.
There are two important points about history-taking which must be mentioned here:
  • Under each system, the absence of the most important symptoms, i.e. dyspnoea and cough in case of respiratory system, dyspnoea on exertion or cardiac pain in case of the cardiovascular system and paralysis or headache or fits in the case of nervous system must be recorded. Their absence influences the diagnosis. The positive symptoms and important negative symptoms on history may give indication of specific involvement of a system.
  • Secondly, the history does not end with the first examination. Continuous notes should be made regarding the disappearance of symptoms or the appearance of new ones, or any other relevant fact.
Course of the illness must be ascertained whether it is acute or insidious onset. How did it progress, i.e. worsened quickly or slowly? Whether there have been relapses or remissions of illness, which would give the intermittent nature of the disease. Sudden events are due to trauma or vascular accidents, etc. Painful disorders and fever indicate infections and neoplasms. Progressive or chronic nature of the disorders points to degenerative origin of the disease. Exaggeration and chronicity of symptoms without any ill effect may be due to psychological reasons.
History of Past Illness
The previous or past history should include all events since infancy. Patient may give ready-made diagnosis of his/her illness that occurred in the past. In that eventuality, it must be verified by asking what actually happened during that illness so as to conclude whether diagnosis is likely or less likely. At times, it may be necessary to communicate with doctors or hospitals that have treated the patient in the past.
Patients are usually not interested to tell the past events. They may or may not remember minor events of the past. The relevant past history pertaining to the present symptoms is to be asked by the physician and recorded. For example, history of acute rheumatic fever in cases with rheumatic heart disease is quite relevant. Jaundice in the past, in case of liver disease, may point to the aetiopathogenesis of symptoms of liver disease in the present history.
To ask past history of diabetes in a patient, who is suffering from diabetes mellitus, is not relevant because it is incurable disease and once it manifests, it continues. Therefore, in such a situation, past history should be asked about the age of onset, its progression and any complications during the past. Some relevant past history to be asked and recorded is as follows:
  • Childhood illnesses, e.g. measles, rubella, mumps, whopping cough, chicken pox, rheumatic fever and polio and history of immunisation such as DPT, polio, tetanus, hepatitis B, measles must be asked.
  • Adult medical illnesses, e.g. diabetes, hypertension, tuberculosis, asthma, hepatitis, HIV disease must be asked.
  • In a patient with rheumatic valvular disease, past history of acute rheumatic fever, joints pain, sore throat is helpful, while history of hypertension is to be recorded in a patient with ischaemic heart disease.
  • History of jaundice, haematemesis, malena, disturbed consciousness are to be asked in a case with liver disease. Drug treatment is to be asked if jaundice is present. Past history of amoebic dysentery in a case with liver abscess is important.
  • Past history of chronic bronchitis (cough occurring 3 months in a year for two consecutive years) is relevant to COPD (chronic obstructive pulmonary disease). Similarly, history of episodes of acute breathlessness with wheeze is important in a case with bronchial asthma. Past history of exanthematous fever, respiratory sinus infection, sore throat are important points to be asked in a respiratory case. Long history of fever with cough, haemoptysis is important for tuberculosis of lung.
  • Prolonged history of diarrhoea is relevant to a patient with an intestinal disorder. Episodic pain in abdomen in the past related to meals is relevant to peptic ulcer.
  • Past history of trauma head is significant in a case with neurological disorder.
Importance of Past History
Certain illnesses in the past may produce complications in the present, for example, childhood infectious illness may produce pulmonary complications in adulthood. Similarly adult illness in the past may have important bearing on the symptoms of present illness. Obstetric/gynaecological past history (menstrual history, birth control, and sexual function) carry significance in a female presenting with gynaecological complaints. The past history relevant to various systems is depicted in the Table 1.1.
Difficulties in History Taking
Taking a history from a patient may pose problem for a number of reasons discussed below. Patient may not at all be at fault. The difficulty is created by circumstances, hence, one should bear this in mind and remain objective (rely on signs) and professional throughout. The circumstances that lead to difficulty and their remedial measures given in the Box 4.
Family History
Note the patient's position in the family, the ages of the children and record of their health, important illnesses and cause of death of immediate relatives. If, however, there is question of hereditary disorder, one should enquire about all the relatives and attempt to construct a family tree showing those affected and those who are not affected (Fig. 1.1). The family history serves several functions. First, in rare single gene defects, a positive family history of a similarly affected individual or a history of consanguinous marriage may have important diagnostic implications. Second, in diseases of multifactorial aetiology that have a family aggregation, it may be possible to identify the patients at risk for the disease and to intervene prior to development of overt manifestations. For example, a recent history of weight gain is a more ominous development in a woman who has a family history of diabetes than in one who does not. Ask the family history of each of the following conditions and record if they are present or absent in the family; hypertension, coronary artery disease, hyperlipidaemia, stroke, diabetes, thyroid or renal disease, cancer (specify type), arthritis, asthma, tuberculosis, headache, seizure disorder, mental illness, suicide, alcohol or drug addiction and allergies.
The symbols used in construction of a family tree (pedigree chart) are illustrated in Figure 1.1. The genetic basis is most striking in certain autosomal dominant (Huntington's disease) or X-linked disorders (haemophilia, myopathy). The pattern of inheritance is less apparent in autosomal recessive disorders as sublings just have a 1 in 4 (25%) chance of developing the disorder.
In many common disorders such as hypertension or coronary artery disease, the mode of inheritance is complex and variable under the environmental influences such as diet and smoking. Apparently a common pathological process such as atheroma may present in unrelated manner in a family for example one relative may present with a heart attack and another with stroke. Therefore, environmental factors may emerge through family proximity. For example, a life-long non-smoking woman with a bronchogenic carcinoma may have had a smoker husband who died due to smoke-related illness.
The Social, Personal and Occupational History
This history actually deals with the patient's physical and emotional environment, the surroundings both at home and at work, habits, mental attitude to life and to work. Therefore, ask about the followings:
  • Exact nature of work/occupation: Ask the type and nature of work being done by the patient. You can ask him about former occupations, if any. One should also ask about the attitude towards work, employer and fellow-workers. Try to find out financial worries.
  • Domestic and marital relations: Ask about the marital status. In men, particularly if unmarried, remember the possibility of homosexuality. Both in males and females, homosexuality is frequently associated with personal and social stresses.
    TABLE 1.1   Past history relevance to review of systems
    Ask past history of
    • Joint pain (fleeting in nature) during childhood or adolescence
    • Rubella infection (maternal)
    • HT, and diabetes
    • Risk factors, e.g. obesity, smoking, lack of exercise, family history of heart attacks, etc.
    • Drug treatment, if any
    Rheumatic fever, rheumatism
    Congenital heart disease
    Coronary artery syndromes
    Coronary artery disease
    Congestive heart failure, arrhythmias
    • Viral exanthems, polio, influenza
    • Allergy/asthma
    • Tuberculosis
    • Status of immunisation
    • Epilepsy/convulsion
    • Ear, nose, throat infection
    • Surgery over upper respiratory tract
    Predispose to respiratory disease
    Respiratory allergic disorders and asthma
    Reactivation or reinfection or post-tubercular complications
    Partial immunisation or unimmunisation predispose to disease
    Aspiration of secretion and predisposition to infection
    May complicate to involve respiratory tract
    Inhalation of infected secretion and predisposition to respiratory infection
    GI tract
    • Recurrent pain abdomen, vomiting, diarrhoea
    • Haematemesis and/or malena
    • Prolonged diarrhoea
    • Expulsion of worms
    Recurrent pancreatitis, cholecystitis, erosive gastritis, parasitic infection
    Peptic ulcer, erosive gastritis, cirrhotic portal hypertension, Mallory-Weiss syndrome
    Chronic diarrhoea/malabsorption/steatorrhoea
    Round worm infestation
    • Alcohol intake
    • Haematemesis and malena
    • Jaundice
    • Drug treatment
    • Recurrent biliary colic
    Alcohol related disorders
    Cirrhotic and non-cirrhotic portal hypertension
    Cirrhosis, hepatitis
    Cirrhosis, drug induced hepatitis
    Stone in biliary system
    Urinary system
    • Recurrent renal/ureteric colic
    • Recurrent fever with chills and rigors
    • Any change in frequency or colour of the urine
    • Instrumentation/catheterisation
    Stone in renal or urinary tract, urinary tract infection, obstructive nephropathy
    Urinary tract infection (UTI)
    UTI, haematuria, haemoglobinuria, drugs
    Predisposition to infection
    • Menstrual history
    • Birth control (medications)
    • Sexual history
    • Alcoholism and smoking
    • Difficult labour
    Endocrinal disorder
    Oral contraceptive related disorder
    Sexually transmitted diseases
    Delivery of low birth weight children
    Injury to urinary tract and predisposition to infection
    Endocrinal and metabolism
    • Childhood diarrhoea/malabsorption
    • Candida infection (mouth, GI tract, nails)
    • Drug history (e.g. antidiabetic, steroids, hormone replacement therapy)
    • Profuse postpartum bleeding
    • Diabetes
    Coelic disease, hypopituitarism
    Candida endocrinopathy
    Seehan's syndrome
    • Recurrent, headache, visual disturbance, vertigo
    • Repeated convulsions
    • Head trauma
    • Muscular weakness
    • Chronic diarrhoea/malabsorption
    • Alcohol use
    Migraine-related disorders
    Subdural haematoma, head injury related brain disorder
    Nutritional deficiency disorders including peripheral neuropathies
    Alcohol related neurological diseases
    Ask past history of
    • Any bleeding in the past or recurrent episodes
    • Family history of deep tissue bleeding/joint bleeding
    • Dietary history
    • Chronic diarrhoea
    • Excessive bleeding from any site
    Bleeding disorders (vascular or thrombocytopenic)
    Haemophilia A and B
    Anaemia and nutritional disorders
    Parasitic infestation and anaemia
    Bleeding/coagulation disorder, anaemia
    Try to find out his/her relation with other family members/friends. The life study of the patient should be explored by asking his/her hobbies, interests, fear, hopes, games played or other source of entertainment, etc.
  • Home surroundings: Ask about his house whether it is made of mud (kuccha house) or bricks and cemented (pucca). Ask about the sanitary conditions, any possibility of overcrowding or loneliness. What pets are kept?
Smoking, alcohol drinking and abusing drugs contribute to the disease, hence, inquiries into these habits is often necessary. Patient may be defensive and may deny or minimise their substance use, in such a situation questioning should be tactful, firm and persistent to get the full information either from him or from a relative.
  • Determine status of smoking of the patient, e.g. smoker, an ex-smoker or a life-long non-smoker.
  • If patient is smoker, then determine;
    • – Form of smoking (cigarettes, bidi, cigars, pipe), quantity (number of cigarettes/bidi/cigar smoked/day) and duration of smoking.
  • If the patient is ex-smoker, note the length of time since the patient stopped smoking.
In smoker, the possibility of tobacco related disease should be considered (Fig. 1.2). It must be remembered that tobacco related diseases are common in both active as well as passive smokers (who just inhale smoke).10
zoom view
FIGURE 1.1: Symbols used for construction of a pedigree charts. First of all draw up a family tree with affected person first found to have trait. Thereafter, relevant informations regarding siblings and all maternal and paternal relatives are included
zoom view
FIGURE 1.2: Bad effects of smoking
  • Ask whether the patient is tea-totallar or drinks alcohol, with the approximate weekly amount (quantity in units).
  • A past or recent history of an alcohol related problem must be noted. Repeated hospital admissions or consultations must be noted.
  • The quantity of alcohol consumed in an week should be calculated. Normally in Indian setting, a small pack of alcohol means 20–30 mL and large back consists of 40–60 mL.
There are two ways of calculating the units of alcohol consumed.
Rough Estimate
Standard measure = one glass of wine, one half pint of beer, one shot of spirits = 1 unit of alcohol.
Calculation of accurate alcohol strength, i.e. 1 unit = 10 mL of pure alcohol × percent proof = units of alcohol/L. For example, 40 percent proof contains 400 mL pure alcohol or 40 units/L so one standard bottle of 750 mL contains 30 units of alcohol. For beer, 4 percent beer contains 40 mL of pure alcohol or 4 units/L, so one large 500 mL bottle can contain 20 units of alcohol.
The detailed history of alcohol intake becomes important;
  • When a man drinks heavily in a binge and could be a suspect of alcohol-induced problem.
  • When excessive drinking is suspected either currently or in the recent past.
  • When an alcohol dependence syndrome exhibiting withdrawal symptoms such as “Shakes” develop.
  • When symptoms are suggestive of alcohol-related disorder. A further questioning relate to assessing the presence of different aspects of alcoholism (Box 5).
Illicit Drug Use
The significance of alcohol intake and its related disorder are depicted in Box 6.
In modern era where illicit drug consumption is rising rapidly, one should not hesitate to ask about it if there is any doubt. However, enquiries should be made in a tactful manner with no adverse effect on patient-doctor relationship.
If illicit drugs are being suspected or have been used; the followings should be noted:
  • The type(s) of drug involved
  • The frequency and duration of use
  • Intravenous use and whether needle-sharing occurred. The needle-related disorders are depicted in Figure 1.3
  • Whether drug dependence developed
  • Any mental, physical or social problem arising from drug use (e.g. indulging in other illegal activities).
zoom view
FIGURE 1.3: Needle sharing disorders
While asking about substance misuse, it is necessary to advise the patient that medical confidentiality affords protection of patient and even if he/she refuses to disclose details of illicit drug-taking, this should be noted.
The social history and its relevance is depicted in Table 1.2.
While taking/recording the history, the doctor/student has to ask certain questions pertaining to his/her presenting complaints. What sorts of questions are to be asked is most challenging task for the students. In fact, the review of systems covers the questions pertaining to symptoms, but on occasions, some physicians also include diseases like tuberculosis, pneumonia, epilepsy, diabetes in the present or past history (if the patient is intelligent, educated and remember important illnesses as you ask questions within the Review of Systems, you can record or present such illnesses as a part of present illness or past history).
The details of questions varies according to state of the patient, nature and severity of illness and relevance of the information sought to the problem/illness under consideration. Always begin with general questions pertaining to various systems in easy understandable language. These focusses the patient attention and enable you to gain confidence of the patient so that you can shift to more specific questions about the system in question.
Under Review of Systems questions may uncover certain problems that the patient has overlooked, particularly in areas unrelated to present illness.
Some physicians do the “Review of Systems” during the physical examination, asking about questions as they examine them. If the patient has only a few symptoms, this combination can be efficient, but if there are multiple symptoms, then the flow of both history and the examination is disrupted and necessary note-taking becomes awkward.
A standard series of review-of-system questions are listed in the Table 1.3.12
TABLE 1.2   The social history and its relevance
  • – Birth injury
  • – Parental attachments and disruptions
  • – Schooling, academic interest and achievements—difficulties if any
  • – Behavioural problems
Domestic life
  • – Emotional, physical or sexual abuse
  • – Experience of death and illness
  • – Interest and attitude of parents
  • – Other occupants of house—any problem, e.g. violence, health and bereavement
Marital status
  • – Married or unmarried
  • – Quality of relationship and any problem of homosexuality
  • – Spouse's occupation
House and surroundings
  • – Type of house—size, owned or rented
  • – Problems with the house
  • – Relationship with neighbours
  • – Status of education
  • – Higher education and further training
  • – Current and previous
  • – Exposure to hazard, e.g. chemicals, accidents, foreign travel etc.
  • – Employment (employed or unemployed—duration and reason)
  • – Financial position (sound or weak)
  • – Any loss of income or debts
Community and family support
  • – Supporting friends or family
Leisure activities
  • – Habits
  • – Use of alcohol, tobacco, caffeine, illicit drugs
  • – Deitary restrictions/eating habit
TABLE 1.3   Systemic symptoms
• Is it increasing, decreasing or stationary?
• Is change in weight of recent onset
• Has the pattern of sleep changed?
• Is there difficulty in getting to sleep or there is early awakening?
• Does the patient feel sleep during the day?
• Does the patient take any medication for it?
• Is there any tiredness?
• Is there any fatigability?
• Is there any general malaise?
A. Upper GI Symptoms
Upper abdominal pain
• What is the site oxf pain?
• How severe is it?
• Is it continuous or intermittent?
• Does it radiate to any site or direction?
• What is duration of pain?
• Are there any pain-free intervals, if yes, what is their duration?
• Is pain related to meal?
• Does it disturb sleep at night?
• What are the aggravating factors?
• What are relieving factors (e.g. food, vomiting or antacid)?
• Is it increased or decreased?
• If reduced, is appetite poor or the patient is afraid of taking food due to pain?
• What is its frequency?
• Does vomiting relieve pain?
• What is the colour of the vomitus?
• Does it contain blood, residues of food taken the day before?
• When does it occur, i.e. morning or evening?
Flatulent dyspepsia
• Does the wind move downwards or upwards?
• Does either relieve symptoms?
Water brash
• Does patient get excessive secretion of saliva into the mouth?
Heart burn
• Does patient feel any pain or burning behind the sternum?
• Does it appear especially after lying down?
• Does sitting up has any effect?
• Is there any difficulty in swallowing?
• Is there any sticking of the food during swallowing?
• Is it worse with solids or liquids?
• Is swallowing painful?
• Is there any associated symptom, i.e. dysphonia or vomiting?
Sour eructations
• Does patient experience acid taste in the mouth?
• Does it have any relation to type of food?
• Does it occur during lying down?
• Is any relieving factor known?
B. Lower GI Symptoms
• What is the frequency of stools? What is the duration of diarrhoea?
• At which part of the day is it more?
• What is their relation to meals or to special articles of food?
• What is the colour of stool?
• Are stool formed (solid) or unformed (liquid) or porridge—like frothy or watery
• Do they float or stick to lavatory pan and difficult to wash them away?
• Has the patient ever passed any blood?
• Is there pain during defecation?
• Is there any incontinence or involuntary passage of stool?
• Any other associated symptoms?
• What is the patient usual bowel habit?
• Has there any recent change in the habit, if yes, then is change related to change in diet, medicines etc.?
• Does constipation alternate with diarrhoea?
• Is there any colicky pain?
• Is there any blood in the stools?
Lower abdominal pain
• What is the localisation, character, and radiation of pain?
• Is it persistent or intermittent?
• Where is it felt worst?
• Is it relieved by defecation or by passage of flatus?
Abdominal distension
• Is there any increase in the abdominal girth?
• Is there any flatulence or dyspepsia?
• Is distension more after taking meals?
• Does the patient has any diarrhoea or constipation?
• Has the patient any psychiatric illness?
Lower GI bleed
• What is the colour of stool? Is the stool black-tarry coloured?
• Are stools mixed with fresh blood?
• Is it painful or painless?
• Has the patient noticed any yellowness of eyes or skin? Is there any change in colour of the urine and/or stool?
• What is the colour of the stool, i.e. pale or dark?
• Does the skin itch (pruritus)?
• Have there been any case of jaundice among family, friends or locality?
• Has there any history of injection/pin prick during the past three months?
• Has the patient visited abroad recently?
• Is there any history of alcoholism. If yes, ask the amount and duration?
• Is the patient a drug addict?
• Where the pain is?
• Has the patient experienced severe attack of pain coming on suddenly and lasting for few hours? If so, did the pain radiate and in which direction?
• Is pain associated with jaundice or jaundice is painless and progressive?
• Did the pain radiate to shoulder or middle of back?
• Is there any history of steatorrhoea (pale, frothy stools)?
• What is its duration?
• Is blood in the vomitus dark-coloured or red coloured (fresh)?
• When did the first episode of haematemesis occurred if it is recurrent?
• What is the amount of blood lost?
• Is there associated tarry-coloured stool?
• Is there any past history of jaundice?
• How short of breath is the patient?
• When does it occur, i.e. at rest or on exertion?
• What degree of exertion is necessary to produce it?
• Are there any attacks of dyspnoea at night (PND)?
• Does the patient sleep with many pillows behind the head (orthopnoea)?
• What is its exact site?
• What is its character, i.e. dull, severe, stabbing, tearing, etc.?
• Is there any radiation of pain to the left arm, neck, shoulder or interscapular region?
• What precipitates it? And what relieves it?
• Is pain present at rest or occurs during exertion?
• Is it relieved by rest or sublingual medication?
• What brings on palpitation and how long does it last?
• Is it paroxysmal or intermittent?
• Is it induced or relieved by exercise?
• Is the heart rate regular or irregular and whether patient experiences any missing of the beat?
• Does the heart give an occasional thump now and then?
Cough oedema
• Ask about cough and expectoration and haemoptysis as detailed under respiratory system?
• Do the feet or ankle swell?
• Are the clothes or shoes tight?
• Is there any associated symptom, e.g. dyspnoea, pain abdomen, cyanosis or abdominal swelling (ascites)?
Other symptoms
• Is there a past history of rheumatic fever, joint pain or chorea (John's major criteria)
• Is there any coldness, blueness or redness of the extremities?
• Is it dry or productive?
• Is it paroxysmal or constant?
• At what time is it worst?
• Is it become worse with cold, dust, smoke or pollen?
• Is it painful or not?
• What is its quantity?
• At what time is it more pronounced?
• What is its colour, odour and consistency?
• Is it purulent or not?
• Is it ever blood-stained (haemoptysis), if, so whether blood comes in streaks or clots and on how many occasions?
• Is patient dyspnoeic?
• Does dyspnoea occur in paroxysms?
• Does dyspnoea occur at rest or after exercise?
• What sort of activity provokes it, e.g. walking upstairs, running for a bus etc.?
• When does wheezing occur?
• Is it constant or intermittent?
• Does anything provoke it, e.g. smoke, dust, pollens?
• Is it worst at any particular time of the day or night?
• What is the occupation of the patient?
Pain chest
What is its exact site, i.e. central or peripheral?
Is it aggravated by deep breathing or coughing?
Is it associated with increase in cough, sputum or dyspnoea?
Whether is it acute in onset?
• Is there any blood in the sputum?
• Is it fresh or altered colour?
• How often does it occur and for how long? Is the blood seen alone, or is it accompanied by purulent sputum?
Other symptoms
• Ask the occupation and exposure to toxic substances and allergans at home or at work place?
• Is patient smoker?
In patients with blood disorders, history carries much significance in addition to symptoms
Lassitude, dyspnoea and palpitation
• Ask about these symptoms
• Is there history of fever? Ask the characteristics of fever?
• Does the patient look pale?
Blood loss
• Is there any history of bleeding from any site, i.e. gums, epistaxis, GI tract, respiratory tract or skin?
• Is there any menstrual disturbance in females?
• Is there any easy bruising?
• Diet history including meat and green vegetable consumption?
• Past history of excessive bleeding following dental extraction/minor procedure
• Family history of bleeding/clotting disorders (haemophilia)
• History of drug intake for aplasia of bone marrow
• Exposure to chemicals
• Any enlargement of glands (lymph nodes)
Urinary symptoms (pertaining to urine)
• How much urine do you pass at a time?
• Does the patient get up at night to pass urine (nocturia)?
• Is the patient continent?
• Is the stream of urine normal or thin?
• Is the urine altered in colour?
• Is it clear or turbid when passed?
• Is there any blood in it (haematuria), if so, at what part of micturition is it present?
• Is there any increased frequency or burning micturition?
• Do you get up at night? How often?
• Is frequency associated with increased thirst (polyuria and polydipsia)?
• Is there any pain during micturition? Is it before, during or after the act? What is its character? And where is it felt?
• Is there any retention of urine with overflow incontinence? Do you ever leak any urine? or wet yourself involuntarily?
Symptoms of renal failure
• Is there any history of loin pain? Does the patient has any attack of pain shooting down into the groin or testes?
• Have any of the symptoms being noticed by the patients, i.e. headache, vomiting, drowsiness, fits, diminished vision, dyspnoea, alteration in urine volume?
• Does the face ever look puffy or oedematous in the morning?
• Are the ankles swollen? (pedal oedema)?
• What is the state of the bowel?
Stroke, e.g. weakness, sensory loss or visual disturbance on one side of the body (hemiplegia, hemianaesthesia, hemianopia)
• Is it transient (TIA—transitory ischaemic attacks recover within 24 hours)?
• Is it persistent >48 hours and then starts recovering (reversible ischaemic neurological deficit)?
• Was headache, vomiting associated with the onset?
• Is there any history of risk factors for cerebrovascular disease, e.g. hypertension, heavy smoking, diabetes or hyperlipidaemia or positive family history?
• Is there any history of heart disease especially vascular disease (for cerebral embolism)?
Epilepsy (seizures consisting of repetitive and even stereotyped convulsions)
• What was your age at first attack? Describe the first attack.
• How frequent do these attacks occur? What is the shortest and longest interval between the attacks?
• Do they occur at night during sleep?
• Is there any aura or warning?
• What is the nature of aura?
• Does the patient become unconscious during attack (complex-partial seizure) or not (simple partial)?
• Does the patient bite the tongue during attack? Examine the tongue for injury.
• Is patient incontinent (involuntary passage of urine and stool) during attack?
• Is there any postictal phenomenon, e.g. headache, somnolence, automatism or Todd's paralysis?
• Is the patient on treatment? Take treatment history.
• Ask about predisposing or precipitating events, e.g. head trauma, ear infection, brain injury, fever and family history.
Other symptoms, e.g. dizziness, speech disturbance, disturbance in memory, proximal or distal weakness and numbness of extremities
• In each instance, ask about the mode of onset, circumstances of onset of symptoms, its progression and specific precipitating and relieving factors.
• Did it follow an injury or viral infection?
• Is dizziness induced by moving the head or by a particular posture?
• Is there any history of systemic disease responsible for neurological complications?
• Is there an evidence of inherited neurological disorder or congenital malformation?
• Is there any history of exposure to toxic substances?
• Is it intermittent or continuous?
• Is visual disturbance associated with it (migraine) or not?
• Is there any family history (migraine)?
• What is the site and localisation of headache? Does it remain on one side or occurs on both sides?
• What are the aggravating or relieving factors, if any?
• Is there any neurological deficit?
Excessive thirst and excessive urine output
• These symptoms may occur in diabetes mellitus, hyperparathyroidism, diabetes insipidus and may be psychogenic. Ask about the other associated features of the disorders mentioned below.
Weight loss or weight gain
• How much weight have you gained or lost?
• Is weight loss associated with good appetite (hyperthyroidism) or poor appetite (malignancy, hypopituitarism)?
• What is duration of weight loss? A long duration of low body weight in young girls indicate anorexia nervosa.
• Is there any associated menstrual irregularity?
• Weight gain indicates obesity which has its consequences on various systems, i.e. joint, heart, metabolism, respiratory and neurological. Ask about their involvement, if any.
• Is weight gain associated with moon-facies, camel's hump, abdominal striae, truncal obesity (Cushing's syndrome) or associated with slow mental and physical activity, constipation and change in voice (hypothyroidism)?
Cold/heat intolerance
• Ask about them. Cold intolerance indicates hypothyroidism and heat intolerance indicates hyperthyroidism.
• Ask about other feature of these disorders.
Sweating, palpitation
• Are they episodic or continuous? Episodes indicate phaeochromocytoma while constant symptoms indicate hyperthyroidism, anxiety.
• Does sweating occur after meals? Gustatory hyperhydrosis indicates autonomic neuropathy.
• Is sweating associated with flushing (carcinoid syndrome)?
• Do they occur during fasting (hypoglycaemia)?
• Do they occur at rest (hyperthyroidism)?
• Do they occur during action (Parkinsonism, cerebellar disease)?
• Are they relieved with alcohol? Alcohol relieves benign essential tremors?
Sexual and menstrual symptoms (e.g. impotence, amenorrhoea, polymenorrhoea, galactorrhoea, hirsutism, gynaecomastia
• Read genital system.
Pigmentation and depigmentation
• Excessive pigmentation occurs in Cushing's syndrome, hence, ask for other features.
• Depigmentation (vitiligo) occurs in autoimmune endocrine disorders and vitamin B12 deficiency.
Family history
• Family history is important in certain endocrinal disorders, e.g. diabetes mellitus, thyroid disorders (autoimmune, dyshormonogenesis), hyperparathyroidism, multiple endocrinal neoplasia).
In male
• Is there any urethral discharge, swelling of the penis and scrotum?
• When does it occur, i.e. at the initiation or end of micturition?
• Is there any history of sexual contact with a women other than his wife?
• Is the micturition painful?
In female
Urethral/vaginal discharge
• Ask the similar question in female as described above?
• Are menses scanty?
• Is menstruation painful?
Menstrual irregularity
Sexual functional complaints, e.g. impotence, premature ejaculation, infertility, impotence, anxiety about masturbation or homosexuality.
• These aspects are to be asked while recording menstrual history in females.
• These are discussed in psychiatric assessment Chapter 20.
Skin disorders may be primary or secondary. The questions to be asked in a case with skin disorders are briefly described here.
• Is there any occupational or other exposure to chemicals or other irritants?
• Ask about recent drug history.
• Does the eruption itch? If so, when does it itch?
• Did the eruptions appear as a single lot or in crops?
• Is there history of allergy, e.g. asthma, hay fever, etc.? Is there any family history?
• Is there any contact with animals, insects or plants?
• What skin medication or application is being used?
• Is there any history of loss of hair (alopecia) or excessive hair (hirsutism)?
• Is there any patch of depigmentation with loss of sensation?
• Is there any present or past history of tuberculosis?
Symptoms of joint disease, e.g. pain, swelling and stiffness.
• Is there pain in a joint or joints?
• Is pain constant or episodic?
• Are there any recurrent attacks of joint pain?
• Is the joint visibly swollen?
• Is there any history of fever, bowel disturbance (inflammatory bowel disease) or urethritis (Reiter's syndrome)?
• Does the pain move from one joint to another (fleeting joint pains of rheumatic fever and gonococcal arthritis). Therefore ask other features of these disorders.
• What is the distribution of joint pain, i.e. whether involves small (rheumatoid arthritis) or large joints (osteoarthritis)?
• Is there any family history of gout or other rheumatic disorders?
• Has the patient been exposed to rubella?
• Is there any gait/posture abnormality?
Soft tissue symptoms such as pain, tenderness and swelling of soft tissue.
• What is the site of these symptoms?
• Is there any history of trauma or overuse during sport?
• What is the occupation of the patient?
• What are the aggravating or relieving factors?
Symptoms of bone disease, e.g. fracture, dislocation, deformity, swelling, pain etc.
• Is there any pain associated with bony enlargement?
• Is there any history of trauma or a stress?
• Is there congenital or family history of bone disorder?
• Is the patient suffering from immunodeficient state?