“Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.” —Sir William Osler
- Brief Discussion and Elaboration about Physical Examination 12
- How to Approach a Long Case 23
- How to Proceed with a Long Case 26
- Systemic Inquiry 29
- Description (or Elaboration) of Symptoms 32
HISTORY OF THE PATIENT
- Name, age, sex, address, marital status, occupation, religion
- Date of admission
- Date of examination
- Chief complaints (in chronological order, from longest to shortest duration)
- History of present illness
- History of past illness (including any operation)
- Family history
- Personal history
- Socioeconomic history
- Psychiatric history
- Drug and treatment history
- History of allergy (to drugs, diet or anything else, skin rash associated with allergy, treatment taken for allergy)
- History of immunization
- Menstrual and obstetric history (in female)
- Other history – Travelling to other places or abroad, working abroad (may be related to hepatitis B, HIV, etc.), contact with TB patient (mention, if relevant).
PHYSICAL EXAMINATION (INCLUDES GENERAL AND SYSTEMIC EXAMINATION)
General Examination
- Appearance
- Build
- Nutrition
- Decubitus
- Cooperation
- Anemia
- Jaundice
- Cyanosis
- Clubbing
- Koilonychia
- Leukonychia
- Edema
- Dehydration
- Bony tenderness
- Pigmentation
- Lymph nodes
- Thyroid gland
- Breasts
- Body hair
- Pulse
- Blood pressure
- Temperature
- Respiration
- Others (if relevant) – Neck, axilla, head (alopecia, large or small). Skin lesion (if any, such as butterfly rash in face, rash in body, scratch mark).
Systemic Examination
Cardiovascular System
- Pulse:
- Rate
- Rhythm
- Volume
- Character
- Condition of the vessel wall
- Radio-femoral delay
- Radio-radial delay
- Neck veins (JVP), hepatojugular reflux (if needed)
- Blood Pressure.
Precordium (Sequentially—Inspection, Palpation, Percussion and Auscultation)
Inspection:
- Any deformity of the chest
- Visible cardiac impulse
- Other impulses (epigastric, suprasternal, supraclavicular or other impulse)
- Any scar mark (midsternal or thoracotomy)
- Pacemaker or cardioverter defibrillator box (mention, if any).
Palpation:
- Apex beat:
- Site (that intercostal space)
- Distance from midline (in cm)
- Nature (normal, tapping, heaving, thrusting, diffuse or double apex).
- Thrill:
- Site (that intercostal space, apical or basal or other site)
- Nature (systolic or diastolic or both).
- Left parasternal heave
- Palpable P2
- Epigastric pulsation.
Percussion:
- Area of cardiac dullness (Not a routine. However, it is important to diagnose pericardial effusion, where area of cardiac dullness is increased and in emphysema, where area of cardiac dullness is obliterated).
Auscultation:
- 1st and 2nd heart sounds
- Murmur:
- Site
- Nature (systolic, diastolic or both)
- Radiation (towards left axilla or neck)
- Relation with respiration, posture (in left lateral position with breathing hold after expiration or bending forward with breathing hold after expiration)
- Grading (1, 2, 3…)
- Added sounds (pericardial rub, opening snap, ejection click, metallic plop)
- Auscultate back of the chest (to see bilateral basal crepitations in pulmonary edema).
Respiratory System
Examination of the chest (systematically—inspection, palpation, percussion and auscultation).
Inspection:
- Shape of the chest
- Deformity (flattening of the chest, kyphosis, scoliosis, etc.)
- Drooping of the shoulder
- Movement of the chest
- Intercostal space (indrawing or fullness)
- Visible impulse
- Visible or engorged vein (if present, see flow)
- Others (scar marks, suprasternal and supraclavicular excavation, prominent accessory muscles, gynecomastia, needle puncture mark, tattooing, radiation mark).
Palpation:
- Position of trachea
- Apex beat
- Chest expansion
- Chest movement (symmetrical or asymmetrical)
- Tracheal tug
- Cricosternal distance
- Vocal fremitus
- Local rib tenderness.
Percussion:
- Percussion note
- Liver dullness
- Area of cardiac dullness (not done routinely, only if emphysema is suspected).
Auscultation:
- Breath sound
- Vocal resonance
- Added sounds (rhonchi, crepitations, pleural rub, post-tussive crepitations).
Gastrointestinal System
(Always start examining from mouth and pharynx, then abdomen).
Mouth and pharynx:
- Lips
- Teeth and gum
- Oral mucous membrane
- Tongue
- Palate and movement of soft palate
- Tonsils
- Fauces.
Abdomen (Examine Systematically—Inspection, Palpation, Percussion and Auscultation) Inspection:
- Shape of the abdomen
- Flanks
- Movement with respiration
- Visible peristalsis
- Visible pulsation
- Umbilicus
- Engorged veins (if present, see the direction of flow both above and below the umbilicus)
- Striae
- Any scar mark
- Pigmentation
- Swelling or mass (tell the site)
- Campbell de Morgan's spot
- Groin, pubic hair and genitalia (with permission of the patient)
- Cough impulse.
Palpation:
- Superficial palpation and local temperature
- Deep palpation (tenderness, rigidity, mass)
- Liver:
- Size (in cm)
- Margin
- Surface
- Tenderness
- Consistency
- Upper border of the liver dullness
- Auscultation (to see bruit or rub).
- Spleen (size in cm)
- Kidneys
- Gallbladder (if palpable, mention the size, tenderness, consistency, surface, margin)
- Fluid thrill (if ascites is suspected)
- Any mass (if present, first see whether it is intra-abdominal or extra-abdominal). Then see the following points:
- Site
- Size
- Shape
- Surface
- Consistency
- Tenderness
- Mobility
- Others: (whether pulsatile, feel for get above the swelling).
- Para-aortic lymph nodes
- Hernial orifice
- Testis (with permission of the patient)
- Per-rectal examination (though it is a part of physical examination, usually it is never done in an examination setting).
Percussion:
- Liver dullness
- Splenic dullness
- Shifting dullness (if ascites is suspected or present).
Auscultation:
- Bowel sounds
- Hepatic bruit or rub
- Renal bruit
- Bruit of aortic aneurysm
- Splenic rub
- Venous hum.
Nervous System
Higher Psychic Functions (HPF):
- Appearance
- Behavior
- Consciousness
- Memory
- Intelligence
- Orientation of time, space and person
- Emotional state
- Hallucination
- Delusion
- Speech.
Motor functions:
- Bulk of the muscle
- Tone of the muscle
- Power of the muscle
- Fasciculation
- Involuntary movement (mention the type, e.g. tremor, chorea, athetosis, hemiballismus, etc.)
- Coordination test:
- Finger nose test
- Heel shin test
- Romberg's sign
- Gait and posture.
Reflexes (Superficial and Deep)
Superficial reflexes:
- Plantar reflex
- Abdominal reflex
- Corneal reflex
- Palatal reflex
- Cremasteric reflex.
Deep reflexes:
Side | Biceps | Triceps | Supinator | Knee | Ankle |
|---|---|---|---|---|---|
Right | |||||
Left |
Clonus:
- Ankle
- Patellar.
Others:
Gordon's sign and Oppenheim's sign (both in leg) and Hoffman's sign.
Sensory functions:
- Pain
- Touch
- Temperature
- Position sense
- Sense of vibration
- Tactile localization
- Tactile discrimination
- Recognition of size and shape, weight and form of object
- Romberg's sign.
Signs of meningeal irritation:
- Neck rigidity
- Kernig's sign
- Brudzinski's sign.
Examination of cranial nerves:
- Olfactory nerve (sense of smell or hallucination of smell)
- Optic nerve:
- Visual acuity
- Field of vision
- Color vision
- Light reflex (direct and consensual)
- Fundoscopy (see last)
- Oculomotor, trochlear and abducent nerve:
- Ptosis
- Squint
- Ocular movements
- Diplopia
- Nystagmus
- Pupils (size, shape, light reflex)
- Accommodation reflex.
- Trigeminal nerve:
- Motor
- Sensory
- Corneal reflex.
- Facial nerve (both sensory and motor)
- Vestibulocochlear nerve: (ask about any hearing abnormality, vertigo or dizziness or giddiness).
- Look at the external auditory meatus (for any wax, rash)
- Rinne's test and Weber's test.
- Glossopharyngeal and vagus nerve:
- Look for nasal voice, nasal regurgitation, hoarseness of voice, bovine cough
- Movement of palate
- Gag reflex
- Taste sensation (in posterior 1/3 of tongue).
- Accessory nerve (spinal part): see the action of sternomastoid and trapezius
- Hypoglossal nerve (look at the tongue and see):
- Wasting
- Fasciculation
- Movement of tongue.
Locomotor System
Bones:
- Shape
- Swelling
- Tenderness
- Deformity
- Sinus.
Joints:
- Inspection:
- Swelling, local muscle wasting (unilateral or bilateral), any deformity
- Redness
- Skin change (psoriatic patch).
- Palpation:
- Temperature
- Tenderness
- Dry or moist
- Fluctuation
- Crepitus.
- Movement:
- Observe the range of active movement while gently palpating the joint for abnormal clicks or crepitus
- If restricted, gently perform passive movement and check for crepitus
- Perform passive stretching maneuvers to detect joint instability or ligament injury (when appropriate).
Spine:
- Look for any kyphosis, scoliosis, lordosis
- Any swelling of vertebral column (local swelling, Gibbus)
- Tenderness of vertebral column
- Movement of vertebrae (perform Schober's test, if appropriate).
Examination of nerve root compression:
- Straight leg raise: With the patient lying supine, flex the hip with legs extended. Normally, up to 90° hip flexion is possible. But when there is root compression, it will be restricted (patient will feel pain in the lumbar region)
Lasegue's sign: With the knee flexed, flex the hip up to 90°. Now gently extend the knee. The patient will feel pain.
Sacroiliac joint examination:
- With the patient in prone position, apply firm pressure over the sacrum with the hand
- With the patient lying on his side, press down on the pelvic brim.
Others (according to suspicion of cause, examine the individual joint accordingly. For example, in case of rheumatoid arthritis, examine the joints of hands, wrist, feet, etc.).
Genitourinary System
Inspection:
- Scar (nephrectomy)
- Scar of transplanted kidney in the right or left iliac fossa
- Visible mass (including mass of transplanted kidney)
- Small scar of dialysis
- Abdominal distension
- Inspection of scrotum for mass or swelling or edema and penis (with permission of the patient).
Palpation:
- Renal angle
- Kidneys
- Urinary bladder.
Percussion:
- Bladder.
Auscultation:
- Renal bruit.
After completing all of the above, proceed as follows:
Bedside investigations (if applicable):
- Urine for sugar (If diabetes mellitus)
- Urine for albumin (If nephrotic syndrome)
Salient features (Present in the following manner – mentioning the name, age, hailing from, smoker or nonsmoker, diabetic or nondiabetic, hypertensive or nonhypertensive, etc. One example is given below):
Mr. X, a 50-year-old businessman, smoker, nondiabetic, nonhypertensive, hailing from … was admitted in the hospital (or presented) with the complaints of:
- … days/months
- … days/months
- … days/months
Then summarize the history of present illness, past history, social and other history with important negative points in the history.
On general examination—mention the important positive and important negative findings.
On systemic examination—tell the findings of the specific system. Then tell, “other systems reveal no abnormality”.
My diagnosis is … (Tell the diagnosis if it is possible).
If the diagnosis is not clear, then tell in the following manner—“With this history and physical findings, I can tell some differential diagnoses”.
BRIEF DISCUSSION AND ELABORATION ABOUT PHYSICAL EXAMINATION
Always begin with the general examination, followed by systemic examination. Details history will suggest that system or parts of the body should be examined first.
General Examination
Remember, “A doctor must be a good observer, like a detective”. So, before starting general examination, look carefully from head to foot.
- Appearance (ill or well looking, depressed, anxious, Cushingoid, expressionless face)
- Built (obese, emaciated or cachexic, tall, short, normal)
- Nutrition (well nourished, poor, normal)
- Decubitus (on choice, propped up, lateral bending, Mohammedan's prayer position)
- Anemia (see in palpebral part of conjunctiva, tongue, palm, nails, body as a whole). Mention whether it is mild, moderate or severe
- Jaundice (see in sclera, under surface of the tongue, palm, body as a whole). Mention whether it is mild, moderate or severe (deep)
- Cyanosis (see in tip of the nose, lips, ear lobule, tongue, tip of the finger and toes). Comment whether the cyanosis is peripheral or central. Be aware of differential cyanosis (it means cyanosis in toes, not fingers)
- Clubbing (see fluctuation of nail base, angle between the nail and its base, curvature of the nails, look for hypertrophic osteoarthropathy by pressing the lower end of tibia-fibula or radius-ulna). Mention whether it is early clubbing, drum-stick or parrot-beak appearance. Be aware of differential clubbing (it means clubbing in toes, not fingers)
- Koilonychia (feel the nails for dryness, brittleness, flattening, thinning, spooning)
- Leukonychia (white spots in nail or white nail)
- Edema (in leg above the medial malleolus, in sacrum if the patient is recumbent)
- Dehydration (skin turgor, dry tongue)
- Pigmentation (exposed parts, face, neck, palmar creases, knuckles, inner side of the mouth, recent scars)
- Lymph nodes (examine systematically in different areas)
- Thyroid gland (palpable or enlarged). If enlarged, examine in details
- Breasts (normal or enlarged or any mass)
- Bony tenderness
- Body hair distribution (including head, to see alopecia)
- Pulse (rate/min)
- Blood pressure
- Temperature (record in Centigrade or Fahrenheit)
- Respiration (number of respiration per minute, mention if any abnormality found).
(Other findings, though not seen routinely, should be mentioned if present or relevant to individual cases. Examples are – xanthelasma, corneal arcus, xanthomatous nodules, skin rash, alopecia, scratch mark, rheumatoid nodule, Dupuytren's contracture, palmar erythema, Osler's node, splinter hemorrhage, Heberden's node, Bouchard's node, gangrene or nail fold infarct or nail fold telangiectasia, ulceration, wasting, skin rash or Gottron's patch, spider angioma, parotid gland enlargement, striae, Campbell de Morgan's spot, purpura, vitiligo, deformity like kyphosis, scoliosis, lordosis).13
Systemic Examination
(From the history, once you get a clue of a particular disease, examine that system first. Then examine the other systems).
Cardiovascular System (First See Pulse, Neck Veins and BP, then Examine the Precordium)
- Pulse (all the following features should be seen in radial pulse):
- Rate (beat/min)
- Rhythm (interval between two beats)
- Volume—low, high or normal (make sure you lift the arm to see collapsing pulse)
- Character (normal, slow rising, collapsing)
- Condition of the vessel wall (if normal, tell, “neither thicken nor tortuous”)
- Radio-femoral delay and radio-radial delay (or inequality).
Compare all other pulses simultaneously (beware of the carotid pulse that should not be seen simultaneously). Volume and character of the pulse are better seen in the brachial and carotid artery. Collapsing pulse in aortic regurgitation and pulsus alternans in acute left ventricular failure are better seen in the radial artery. - Neck veins (JVP): The patient should lie at 45°.
- Normal or engorged (internal jugular vein that lies medial to the sternomastoid). If visible, see any prominent wave. Always see hepatojugular reflux. Next, measure the height from the sternal angle (it indicates the mean pressure in the right atrium. Normally, it is at the level of the sternal angle and invisible).
- Other signs in neck:
- Tall, sinuous venous pulse, oscillating up to the ear lobule (indicates prominent V wave, found in tricuspid regurgitation)
- Dancing carotid pulse (called Corrigan's sign found in aortic regurgitation)
- Vigorous arterial pulsation in neck (found in coarctation of aorta)
- Other pulsation in neck (carotid aneurysm or subclavian artery aneurysm).
- Blood pressure (BP):
- Measure BP (normal or high).
- Low systolic, normal diastolic and narrow pulse pressure (found in aortic stenosis)
- High systolic, low diastolic and wide pulse pressure (found in aortic regurgitation)
(If needed, see in both arms, also in standing and lying to see postural hypotension).
examination of Precordium
Inspection:
- Deformity of the chest wall (kyphosis, scoliosis, lordosis, pectus excavatum or carinatum)
- Visible cardiac impulse (visible apex beat)
- Other impulses: epigastric, suprasternal, supraclavicular
- Any scar mark: in the midline (valve replacement or coronary artery bypass), thoracotomy scar (valvotomy in mitral stenosis)
- Pacemaker or cardioverter defibrillator box may be seen (mention, if any).
Palpation:
- Apex beat:
- Site (localize the intercostal space. Beware of dextrocardia)
- Distance from the midline (in cm)
- Nature (normal, taping, heaving, thrusting, diffuse or double apex beat).
- Thrill:
- Site (apical, basal or any other space)
- Nature (systolic or diastolic, by feeling the carotid pulse at the same time. If coincides with carotid pulse, it is systolic and if it does not coincide, it is diastolic).
- Left parasternal heave: Place the flat of right palm in left parasternal area and feel by giving gentle sustain pressure (presence of left parasternal heave indicates RVH)
- Palpable P2 (in left second intercostal space): It indicates pulmonary hypertension
- Epigastric pulsation.
Percussion:
Usually not done, may be helpful to diagnose pericardial effusion (area of cardiac dullness is increased) and emphysema (cardiac dullness is obliterated).
Auscultation:
- First and second heart sounds in all four areas (mitral, aortic, pulmonary and tricuspid areas). At the same time, palpate the right carotid pulse with thumb simultaneously. 1st heart sound coincides with carotid pulse, but 2nd sound does not (comes before or after). See also other heart sounds, if present (3rd and 4th).
- Murmur:
- Site (apical, parasternal, aortic or pulmonary area)
- Nature—systolic (pansystolic or ejection systolic), diastolic (mid diastolic or early diastolic)—by feeling carotid pulse at the same time (systolic coincides with carotid pulse and diastolic does not coincide)
- Radiation (pansystolic murmur to left axilla, ejection systolic murmur to neck)
- Relation with respiration (right sided murmur increases on inspiration and left sided murmur increases on expiration)
- Grading of murmur (e.g. 2/6, 4/6).
- Added sounds (pericardial rub, opening snap, ejection click, metallic plop.
- Others:
- Auscultate the back of the chest for crepitations (found in pulmonary edema).
- Palpate the liver (enlarged tender liver in CCF, pulsatile liver in tricuspid regurgitation)
- Splenomegaly (may be found in infective endocarditis).
Respiratory System
(Examine the chest from both front and back – Inspection, Palpation, Percussion and Auscultation).
Inspection:
- Shape (asymmetry, deformity, barrel shaped, pectus excavatum or carinatum, kyphoscoliosis), flattening and drooping of the shoulder (due to fibrosis or collapse)
- Movement (unilateral or bilateral restriction), upward movement (in emphysema). See paradoxical inward motion of abdomen during inspiration with the patient in supine position (indicates diaphragmatic paralysis)
- Intercostal space (fullness, indrawing of lower ribs, Harrison's sulcus)
- Scar mark (thoracotomy scar, thoracoplasty, radiation marks)
- Visible impulse (cardiac, epigastric)
- Visible, engorged vein in chest (SVC obstruction). If present, see the flow
- Others: Suprasternal and supraclavicular excavation, prominent accessory muscles, gynecomastia, needle puncture mark, tattooing, bandage or gauge with tape.
Palpation:
- Position of trachea (deviated to the right or left or central). Normally, it is slightly deviated to the right
- Apex beat (shifted or not)
- Vocal fremitus (normal, increased, decreased or absent)
- Chest expansion (normal or reduced)
- Tracheal tug (descent of the trachea during inspiration. Examine by placing fingers over the trachea. It indicates hyperinflation of lung)
- Cricosternal distance: It is the distance between the suprasternal notch and cricoid cartilage (normally 3 fingers or more. If it is less, indicates hyperinflation)
- Rib tenderness (due to trauma or fracture, secondary deposit), tenderness in costochondral junction (due to Tietz's syndrome).
Percussion:
- Percussion note (normal resonance, hyper-resonance, stony dull, woody dull, impaired)
- Area of liver dullness (normally in 5th ICS in the right mid-clavicular line. It is obliterated or lower down because of emphysema or severe asthma).
- Area of cardiac dullness (obliterated because of emphysema or severe asthma).
16Auscultation: (Turn the head of the patient to the left side and tell him, “Keep your mouth open, take deep breath in and out for me”. Place the stethoscope. Auscultate in both right and left sides alternately).
- Breath sound (normal vesicular, vesicular with prolonged expiration, bronchial, diminished vesicular or absent)
- Vocal resonance (normal, increased, decreased or absent)
- Added sounds –
- Rhonchi (high or low pitched, localized or generalized)
- Crepitations (fine or coarse or end inspiratory. If crepitations are present, ask the patient to cough and auscultate again whether the crepitations are diminished, absent or same). Post-tussive crepitations that appear after cough may be found in tuberculosis
- Pleural rub.
Ask the patient to sit forward, examine the back of chest systematically.
Finally see the following points:
- If your diagnosis is COPD, see FET (forced expiratory time), by asking the patient to exhale forcefully after full inspiration, while you listen by placing your stethoscope over the trachea. Normally, it is < 6 seconds. If > 6 seconds, indicates airway obstruction
- If any sputum cup is available nearby, look at the sputum and comment on it.
Gastrointestinal System
Mouth and pharynx:
- Lips (cyanosis, inflammation, any swelling, ulceration, angular stomatitis, pigmentation)
- Teeth (number, infection at the root, tartar, dental caries, Hutchinson's teeth)
- Gum (color, signs of inflammation, swelling or hypertrophy, ulceration, bleeding)
- Palate, movement of soft palate
- Tongue (color, papillae, dry or moist, ulceration, inflammation, presence or absence of fur, coating, white patch, candidiasis)
- Oral mucous membrane (colour, pigmentation, inflammation, ulceration, swelling, opening of the parotid duct)
- Tonsils (inflammation, swelling, pus formation, ulceration, membrane)
- Fauces (see any patch, redness, ulceration).
Abdomen (Inspection, Palpation, Percussion and Auscultation).
Inspection:
- Shape of the abdomen—normal or distended or shrunken (scaphoid). If distended, whether generalized or localized (in epigastrium, right or left hypochondrium or iliac fossa, central part)
- Movement of the abdomen—ask the patient to take deep breath in and out, inspect from either leg or head end (to see whether the movement is equal in all sides)
- Visible peristalsis (present or absent)
- Visible pulsation (in the epigastrium)
- Umbilicus (inverted or everted)
- Visible veins—tell where (central part, flank, below or above the umbilicus, around the umbilicus). If present, see the flow both above and below the umbilicus
- Striae—tell where (color, size, vertical or horizontal)
- Any scar mark (because of surgery, trauma), fistula (Crohn's disease), stoma (colostomy, ileostomy, ileal conduit)
- Pigmentation (linea nigra from below umbilicus, erythema ab igne)
- Mass or swelling (tell the site, see whether it is intra-abdominal or extra-abdominal)
- Campbell de Morgan's spot (small, red, nodular lesion, common in middle age or elderly)
- Finally look to the groin (ask the patient to cough), pubic hair, genitalia (with permission of the patient).
Palpation:
- Inquire any pain in abdomen (examine that part last) and tell the patient, “Please tell me, if I hurt you”
- Ensure that your hand is warm, put the palm gently rather than the tip of the finger, keeping the hand flat on the abdominal wall with a gentle flexion of metacarpophalangeal (MCP) joints
- Better if you are in horizontal position with the patient, wrist and forearm in the same horizontal plane, by bending or kneeling by the side of the patient
- During palpation, look to the patient's face to see whether he or she “winces” with pain
- If ascites, do not forget to palpate by dipping technique.
- First, perform superficial palpation—feel for rigidity or any mass. Hard periumbilical lymph node (called “Sister Marie Joseph's nodule” is highly suggestive of metastasis from pelvic or GIT primary tumor)
- Tenderness (occasionally rebound tenderness may be seen—press the abdomen slowly, then release suddenly. Pain may be present that indicates peritonitis)
- Liver—start from right iliac fossa, ask the patient, “turn your face to left side, keep your mouth open, take deep breath in and out”. Press and proceed during inspiration and look at the patient's face. If the liver is palpable, see the following points:
- Measure in cm from the costal margin in the right mid-clavicular line. If left lobe is enlarged, measure from xiphoid process. Always measure with tape (not with fingers)
- Margin (round or smooth or sharp)
- Tenderness (tender or nontender)
- Surface (smooth or irregular)
- Consistency (soft or firm or hard)
- Upper border of the liver dullness (using heavy percussion, but percussion of lower border using light percussion)
- Auscultation (to hear bruit or rub).
- Spleen (keep your left hand in lowermost part of left side of chest posterolaterally with slight pressure. Starting from the right iliac fossa, ask the patient, “turn your face to left side, keep your mouth open, take deep breath in and out”. If it is not felt, turn the patient halfway toward right and palpate again. Once the spleen is palpable, see the following points:
- Measure in cm along its long axis from costal margin in anterior axillary line towards right iliac fossa (also from costal margin in left midclavicular line downward)
- Feel splenic notch (definitive sign of splenomegaly)
- See – get above the swelling of spleen (insinuate right index finger between spleen and left costal margin)
- See margin, surface, consistency and tenderness
- Percuss over the spleen and continue up to left lower part of chest (to see the continuation of splenic dullness)
- Auscultate over the spleen (to see splenic rub)
- Palpate both right and left kidney (by ballottement)
- Gallbladder
- Any mass (see below)
- Feel for para-aortic lymph nodes
- Urinary bladder
- Palpate the hernial orifice (ask the patient to cough, see and palpate)
- Palpate the testis (with permission of the patient)
- Finally per-rectal examination (tell if the examiner ask). Never done in examination.
Percussion:
- Usually a light percussion is done. Note the normal tympanic sound or any dullness
- If there is suspicion of ascites, elicit shifting dullness
- Fluid thrill (only necessary, if there is tense ascites).
Auscultation:
- Auscultate (normal bowel sound, increased borborygmi or reduced or absent bowel sound)
- Over liver (hepatic bruit or rub)
- Renal bruit (2 cm above the umbilicus and lateral to mid line)
- Bruit of aortic aneurysm (if any)
- Splenic rub (rarely present)
- Venous hum (heard between xiphisternum and umbilicus). It is a continuous, low pitch soft murmur. Presence of venous hum indicates portal hypertension (rare finding). It is because of large volume of blood flowing in umbilical or paraumbilical vein in falciparum ligament due to portosystemic shunt.
If you get any mass, see the following points:
First, see whether it is intra-abdominal or extra-abdominal. Ask the patient to raise his head and press over the forehead. Now see and palpate the mass again. If it disappears or less prominent, it is intra-abdominal. If it is more prominent, likely to be extra-abdominal.
Next see the following points of a mass:
- Site
- Size
- Shape (round, regular or irregular)
- Surface (smooth or irregular)
- Consistency (soft, firm or hard)
- Tenderness
- Mobility (mobile or fixed).
Nervous System
Higher psychic functions (HPF):
- Consciousness (conscious, semiconscious, unconscious or drowsy)
- Appearance and behavior (normal or violent)
- Memory – Recent and past (intact or not)
- Intelligence (normal or less)
- Orientation of time, space and person (normal or absent)
- Emotional state (normal or labile)
- Hallucination and delusion (present or absent)
- Speech (normal or dysarthria or aphasia or dysphasia or aphonia).
Motor functions:
- Bulk of the muscle (normal or wasted or hypertrophied)
- Tone of the muscle (normal, hypotonia or hypertonia)
- Power of the muscle (normal or diminished, mention the grading of weakness)
- Involuntary movement (present or absent. If present, mention the name, e.g. tremor, chorea, athetosis, etc.)
- Coordination:
- For upper extremity—finger nose test
- For lower extremity—heel shin test
- Romberg's sign (positive or absent)
- Gait (mention the specific type of gait).
Reflexes:
- Superficial reflexes:
- Plantar reflex (normal flexor, extensor or equivocal).
- Abdominal reflex (absent or exaggerated)—elicited by stroking upper and lower quadrant of the abdominal wall of each side. If present, there is contraction of abdominal muscles (It represents 7th and 12th thoracic segments)
- Corneal reflex (present or absent)
- Palatal reflex (present or absent)
- Cremasteric reflex (present or absent)—elicited by stroking skin at upper and inner part of thigh. Normal response is an upward movement of testicle (It represents L1 and L2).
- Deep reflex (mention whether it is normal, exaggerated, reduced or absent):SideB (Biceps)T (Triceps)S (Supinator)K (Knee)A (Ankle)RightLeft
- Clonus (sustained clonus indicates upper motor neuron lesion)-
- Ankle
- Patellar
- Other reflexes:
- Hoffman's sign (elicited by briskly flicking down the patient's tip of the middle finger with the examiner's thumb and index. If there is flexion of thumb or all fingers, it is positive. It indicates extensive upper motor neuron lesion)
- Gordon's sign (elicited by pinching the calcaneus tendon. If present, there is extensor plantar response)
- Oppenheim's sign (elicited by squeezing the calf or pressing heavily along the inner border of the tibia. If present, there is extensor plantar response).
Sensory functions:
- Superficial sensations (normal, reduced or absent):
- Touch (with cotton)
- Temperature (with both cold and warm)
- Pain (with pin).
- Deep sensations:
- Deep pain (elicited by squeezing a distal muscle or Achilles tendon. This sensation is particularly disturbed in tabes dorsalis)
- Tactile localization
- Tactile discrimination.
- Position sense (intact or impaired)
- Vibration sense (normal or decreased)
- Recognition of size, shape, weight and form of object
- Romberg's sign (positive or absent).
Signs of meningeal irritation:
- Neck rigidity—Normally chin can be flexed passively to touch the chest. It is not possible, if neck rigidity is present.
- Kernig's sign—Flex the knee and hip. Then gradually extend the knee. If meningeal irritation is present, patient will complain of pain (because of spasm of hamstring muscle).
- Brudzinski's sign—It is elicited with the patient in supine position and is positive when passive flexion of the neck results in spontaneous flexion of the hips and knees.
Examination of cranial nerves:
Ask the patient to sit at the edge of bed, face to face. See any obvious finding (ptosis, squint, asymmetry of face, dribbling of saliva). Now, examine the individual cranial nerve as follows:
1st Olfactory nerve:
- Examine the nasal cavity with a torch light to see any DNS, polyp
- Sense of smell (ask the patient, “Do you have any difficulty in your sense of smell?” Then examine the sense of smell, ideally by using a perfume. Put in each nostril and ask, “Do you get the smell?”).
2nd Optic nerve (ask the patient whether he uses any glass. If so, ask to put it on and do the examination. Remember, each eye should be examined separately).
- Visual acuity: Both distant and near vision should be examined. Ideally, Snellen's chart should be used. If not available, proceed as follows:
- Distant vision—ask the patient, “look at the wall clock. What is the time now?” “Look at the window. How many rods in the window?”
- Near vision—tell the patient “read the newspaper or any small object”.
- Color vision: Ideally it should be done with Ishihara chart. If not available, show different colors to the patient and ask, “what color is it?”
- Field of vision: Sit opposite to the patient, one meter apart at a same plane. Test each eye separately in the following way:21
- To examine right eye, ask the patient, “cover your left eye with left hand gently, look steadily at my left eye”. You should cover your right eye. No one should move the eye and should look each other's tip of the nose.
- Hold your index finger midway and from periphery, bring toward the center until you see it. Ask the patient “do you see my finger? Tell me when you see it.”
- If patient fails to see, continue to bring the finger and ask him, “tell me when you can see”.
- In this way, see in horizontal, upper and lower quadrant (temporal field).
- Then, see nasal field in the same way.
- Change your hand and repeat in other eye in the same manner.
- Test of central scotoma—Use a red headed pin, move it from temporal side to nasal side in the midway. Ask the patient, “Do you see it? Tell me, when it disappears”.
- Fundoscopy (should be done at the end).
3rd, 4th and 6th Oculomotor, trochlear and abducent nerves:
- Look for ptosis or squint
- Ocular movements:
- Ask the patient, “Look at my finger. Follow it with your eyes with head fixed”
- See movements in horizontal and vertical directions like the pattern “H”
- See nystagmus. At extreme gaze, ask, “Do you see one or two fingers (diplopia)?”
- Pupils: size, shape, light reflex (both, direct and consensual—put light directly on one eye and see in other eye)
- Accommodation reflex (Ask the patient to look at a distant object. Then put your finger in front of his or her eyes. Now ask, “Look at my finger”. See the movement of the eyeball and also pupil).
5th Trigeminal nerve (test both motor and sensory):
- Motor:
- Look for wasting of masseter and temporalis
- Ask the patient to clench his teeth and palpate the muscles. Then ask him to open the mouth, while you try to keep it closed (test for pterygoids). If paralysis is on one side, muscle of that side is less prominent and jaw deviates toward the side of lesion
- See jaw jerk (exaggerated or not).
- Sensory:
- Test along 3 divisions (ophthalmic, maxillary and mandibular) of nerve on each side using cotton and pin with eye closed
- See corneal reflex with a wisp of cotton. Touch the cornea (not conjunctiva), see if there is reflex blinking (afferent or sensory component is mediated by ophthalmic division of trigeminal nerve and efferent or motor component is mediated by facial nerve).
7th Facial nerve (perform both motor and sensory tests):
- Look at the face and see the following (which are present in 7th nerve palsy):
- Facial asymmetry and affected eye appears open and wide
- Drooping of corners of the mouth (unilateral or bilateral)
- Nasolabial fold (less pronounced).
- Motor tests:
- Ask the patient to look at the ceiling, keeping the head fixed and see any wrinkling of forehead, either unilateral or bilateral (frontal belly of occipitofrontalis)
- Ask the patient to close the eyes tightly and not to let you open it (orbicularis oculi). If failure to close, look for Bell's phenomenon
- Ask to whistle (orbicularis oris)
- Ask the patient to puff cheeks out (buccinator). If paralysis, air is escaped easily on the affected side
- Ask to show the teeth and to smile (levator anguli oris and risorius). If paralysis present, face is drawn to the healthy side.
- Sensory tests: Taste sensation of anterior 2/3rd of the tongue
- Finally, look at external auditory meatus and palate to see any rash (Ramsay Hunt's syndrome). Also, test for hyperacusis (nerve to the stapedius muscle).
8th Vestibulocochlear nerve:
- For vestibular division: Ask the patient about vertigo, dizziness or giddiness.
- For cochlear division:
- Look at the external ear and meatus (wax, rash)
- Rub hair or put the watch near the ear and ask the patient, whether he can hear or not
- Rinne's test and Weber's test may be necessary in some cases. Normally, air conduction is more than the bone conduction.
9th and 10th. Glossopharyngeal and Vagus nerves:
- While talking with the patient, observe any nasal voice or hoarseness. Presence of hoarseness indicates bilateral paralysis of superior laryngeal branch of vagus. If it is unilateral, usually the patient is asymptomatic
- Ask about nasal regurgitation
- Movement of the palate: Ask the patient, “open your mouth and say, aah”. If one side remains flat and immobile, indicates paralysis of that side (soft palate is pulled to the normal side)
- Ask the patient to cough. If there is bovine cough, it indicates recurrent laryngeal nerve palsy
- Gag reflex (palatal reflex, 9th nerve): Touch the back of pharynx and see constriction
- Taste sensation in posterior 1/3rd of tongue (9th nerve).
11th Accessory nerve (spinal part):
- Ask the patient “Shrug your shoulder against resistance” (trapezius)
- Ask the patient “Turn your head to the other side against resistance”. Feel sternocleidomastoid (test on both sides).
12th Hypoglossal nerve:
- Look at the tongue to see wasting, fasciculation or small and spastic or tight tongue
- Movement of tongue: Ask the patient to put out his tongue and observe the following:
- If small and spastic (unable to protrude)
- Deviation (toward the weak side).
- Ask the patient to waggle the tongue side to side. Feel the weak side.
HOW TO APPROACH A LONG CASE
“Practicing long case trains a physician to be a good clinician”
Vital parts of long cases include the following points:
- Detailed history taking
- Physical examination (general and systemic)
- Provisional diagnosis
- Differential diagnosis
- Investigations
- Management.
Proceed in a systematic way as above. Time allocation is very important. There is a fixed time given in any examination and a candidate should divide the time according to the case:
- Few minutes for history taking
- Few minutes for physical examination
- Few minutes for the formulation, plan of investigations, differential diagnosis and management
- Finally, few minutes for recapitulation of the case, as how to present the case and face the interpretation by the examiners.
Examiner usually asks:
- Present your case (mention the salient features)
- What is your diagnosis? (Remember this may be the first question. So, tell the diagnosis). Then you will be asked “Why do you think this is the diagnosis?” If the diagnosis is clear, then tell the brief history and important positive physical findings. From this history and physical findings my diagnosis is this. If no clear cut single diagnosis, then you can say, “with the history and physical findings, I can tell the differential diagnosis”
- What are the other possibilities (or differential diagnoses)? Why is it not a case of …? (Mention the points against that diagnosis)
- What investigations do you want to do in this case? What do you expect?
- How can you confirm the diagnosis?
- How will you treat the patient?
- What is the prognosis?
Remember, examiner usually interrupts at any point and you must be ready to interpret the history, physical findings, diagnosis, differential diagnosis, investigation and treatment.
Remember, during discussion of a long case, examiner usually expects or examines:
- Candidate's skill and art of taking history
- Candidate's ability to examine the patient systematically and gently
- Candidate's ability to come to a diagnosis and formulate management plan that includes investigations with interpretation of the result and treatment (symptomatic and specific).
BEFORE STARTING TO TAKE HISTORY
Careful history taking is the most fundamental and important aspect of a clinical case. Skill for good history taking can be achieved by regular practice, allocating time and having patience. Diagnosis is possible only by taking a good history, even without unnecessary investigations. A correct diagnosis is missed, not because of lack of knowledge, but because of not listening attentively to the patient or not asking the relevant questions.24
- Always introduce yourself, in the following manner, “Good morning. I am Dr. … I would like to talk with you regarding your problems and if you kindly allow me, I would like to examine you” (In such a way, you can gain interest, confidence and cooperation of the patient. An intelligent patient may tell the diagnosis, treatment, etc.).
- Make a handshake and observe for any abnormality (like warm sweaty hand, tremor, slow relaxation of the handgrip).
- Check whether the patient is comfortable. Try to put the patient at ease (a good rapport may relieve distress on its own).
- Be polite, gentle, cordial and respectful to the patient (history taking is an art and beginning of doctor-patient relationship, depending on which the patient will develop confidence on the doctor).
- While you are appearing in an examination, explain to the patient that, “This is an important examination in my life. Your cooperation is very essential for me”.
- While talking to the patient, watch him very carefully (patient may be anxious, apathetic or there may be obvious abnormality like myxedema, Graves’ disease or Parkinsonism). Observe the nature of speech or any voice change during talking with the patient.
- Notice nonverbal clues for the diagnosis.
You must develop a good clinical eye that is extremely essential to be a good clinician. While taking history, listen to the patient carefully, and at the same time, keenly observe:
- From head to foot (gross abnormality may be obvious)
- Facial expression
- Posture
- Obvious pallor or jaundice
- Any swelling or goiter.
By observation, the diagnosis may become obvious or this will provide important clue for the diagnosis (e.g. thyrotoxicosis, myxedema, Parkinson's disease, Cushing's syndrome).
Remember the following points:
- Occasionally, if the patient is unable to give the history (such as elderly, very ill, children or aphasia), it is necessary to take history from the attendant or relative. This will also help to alert the physician, if anything is concealed by the patient. However, always try to take the patient's consent first.
- If there is possibility of drug abuse or alcoholism, ask the patient very gently and with confidentiality. Otherwise, the patient may either refuse or hide.
- Many a times, the patient tells his history in his own words. There may be irrelevant informations given by him. But you should listen attentively with patience. Unnecessary part of the history should be avoided.
- Sometimes, the patient is uncooperative, irritable or angry. In such a case, you must be more careful to make every effort to calm him down. Even if you feel irritated or angry, never show this to the patient.
- An intelligent patient may give a definite diagnosis. Even you can ask “Do you know the name of the disease from which you are suffering? What drugs are you taking? Can you mention if any procedure has been performed (e.g. aspiration of pleural fluid, peritoneal fluid, etc.)?” This will give valuable informations regarding the diagnosis, past and present problem.
- If the symptoms do not correlate with the real diagnosis, proceed with further questions. He may tell the symptoms that he has forgotten or failed to mention. However, you will have to formulate a final history of the patient before presenting to the examiner.
- Many patients may have multiple problems and multiple diagnoses. Organize to present the most important diagnosis first.
- At the end, always ask the patient, “Would you like to say anything else?”
HOW TO PROCEED WITH A LONG CASE
(Elaboration and description)
“A good history is the biggest and most important step towards the correct diagnosis.”
After asking full name, age, sex, address, occupation, marital status, etc. start by the chief complaints.
Chief Complaints:
- Start by asking “Would you please tell me what's wrong with you?” Or, “Why are you admitted in the hospital?” Or, “What are your presenting problems?” Or, “What has been the trouble recently?”
- Try to elicit the main complaints with their time frame
- Precise chronology and sequence of events are very important
- Note the symptoms of longest duration, followed by the other symptoms in decreasing order, finally mentioning the symptom with shortest duration (suppose fever for 6 months, headache for 3 months, loss of appetite and weakness for 1 month).
History of present illness:
- Elaborate the chief complaints in details mentioning the following (mnemonic: OD PARA):
- Onset—How did it start? When did it start?
- Duration—How long?
- Progression—Is it progressive or static?
- Aggravating factors—What makes it worse?
- Relieving factors—What makes you feel better?
- Anything else—Do you have anything else to mention?
- Elaboration of some common symptoms has been discussed as ‘Description of symptoms’ on page no 32.
- Important negative parts of the history should be included if relevant.
- Information in patient's own words is more valuable, but sometimes leading questions are also necessary.
- Vague symptoms, such as “not feeling well”, “head is hot”, “stool is not clear”, etc. should be precisely clarified. If a symptom is irrelevant, it may be ignored.
- Inquire whether the patient has been suffering from diabetes mellitus, hypertension or bronchial asthma or other chronic illness.
- Record the patient's own words, avoid using medical terms. For example, instead of “dyspnea”, mention “difficulty in breathing”, “vomiting of blood” should be noted instead of “hematemesis”, instead of “anorexia” mention “loss of appetite”.
History of past illness:
Every history of the past illness, including any event during childhood or infancy, should be recorded, as follows:
- Previous diseases with its details (duration, treatment taken, whether hospitalized).
- History of any operation, injury, trauma and procedure (catheterization, endoscopy, colonoscopy, biopsy).
- History of any investigation.
- Ask about diabetes mellitus, hypertension or other chronic illness. In case of CLD, enquire about past history of jaundice or if the patient has cardiac problem, enquire about history of rheumatic fever, hypertension, dyslipidemia.
- Ask about childhood illnesses including birth complications, immunization history, development and diseases.
Family History:
Detailed history of all the members of the family is very important. Ask about the following:
- Number of family members (parents, spouse, children, etc.)
- Their state of health. Ask – “Are they in good health?” “Do they have any illness? (e.g. ask about history of tuberculosis, hypertension, diabetes mellitus, dyslipidemia, ischemic heart disease, thyroid disorder, bronchial asthma, etc.)
- If death among family members, enquire the cause of death
- Ask about hereditary conditions (e.g. thalassemia), inquire regarding marriage among relatives (consanguinity)
- If X-linked disease is suspected, ask specifically about the health of maternal uncles.
Personal history:
Detailed personal history must be included:
- Occupation (exact nature of work)
- Marital status
- Dietary habit
- Hobby, pet keeping (cows, dog, rabbit, pigeon, etc.), interest, games, any source of entertainment
- Tea or coffee, betel nut
- Smoking (with number of sticks daily with duration) or tobacco chewing—ask technically specially in females who feel shy. If the patient is an ex-smoker, ask when he has stopped smoking and the number of sticks with duration that he used to smoke. Also, enquire any possibility of passive smoking.
- Alcohol (how much and how long, daily, weekly, occasional, place of drinking—home, outside, alone or socially). Be strategic as patient may not be forthcoming.
- History of drug abuse including alcohol, intravenous drug use, sharing of needles. Enquire about drug dependency, any social or physical problem arising from drug use. Again be careful regarding the confidentiality of the information.
- Sexual exposure or sexual practice including homosexuality, polygamy, etc. (ask strategically, without embarrassing the patient).
Socioeconomic history:
- Home and its surrounding environment—nature of house such as apartment, slum area, wooden house, living status, over-crowding, water supply and sanitation
- Office environment
- Income and employment
- Social and family relationship
- Any dependents at home? Who else at home?
- Who visits the house? (relatives, neighbor, friends).
Drug and treatment history:
- Details of drugs (previous and present)
- History of drug allergy, drug intolerance or reaction
- Treatment already received for present illness
- History of any transfusion (blood, plasma, blood product, normal saline or other fluid) received.
Immunization History:
- History of immunization is very relevant (hepatitis B, tuberculosis, tetanus).
Traveling history:
Travel or job outside the country (helpful for diagnosis of malaria, amebiasis, hepatitis B, HIV).
Psychiatric history:
Any symptoms related to anxiety, depression, dementia, hallucination, delusion, phobia, sleep pattern.
In female patient, always remember to ask 3 P –
- Period (menstrual history, such as amenorrhea, polymenorrhea, menorrhagia)
- Pill (oral contraceptive pill or other contraceptive method)
- Pregnancy (obstetric history, e.g. number of child, age of last child, postpartum hemorrhage, abortion or repeated abortion).
To remember the format of history taking for long case, use the formula:
SYSTEMIC INQUIRY
(Review of Different Anatomical Systems)
Sometimes, the patient may forget to mention important symptoms or may feel it unimportant or feel shy or guilty about it. So, systematic symptom inquiry (not mentioned by the patient), may give some clue to the diagnosis. Ask the questions in relation to particular anatomical systems of the body. Always begin with open questions without medical jargon. Some of the questions in different systems are given below. This may vary according to the state of patient, nature and severity of illness. Ask as follows:
General symptoms and others:
- Do you suffer from fever? If yes, ask details (see on page 33).
- Do you have night sweats?
- Have you gained or lost weight? If yes, ask details (see on pages 50 and 51).
- Have you noticed any swelling on your body? If yes, ask details (see pages 52 and 53).
- Do you feel unusually weak, lethargy, malaise or fatigue?
- Do you feel excessive sweaty or cold?
- Have you noticed any change in your complexion (pale, darkening, yellowish)?
- How is your sleep? Is there any change of sleep pattern, difficulty in getting to sleep, early awakening or feeling sleepy during the day? (Increased day time sleepiness occurs in hepatic precoma or obstructive sleep apnea).
- Do you have any skin rash or itching?
Cardiovascular system:
- Do you have chest pain or discomfort or tightness in your chest? If yes, ask details (see page 37)
- Do you have difficulty in breathing? If yes, ask details (see pages 39 and 40)
- Do you have cough? If yes, ask details (see pages 38 and 39)
- Did you notice any swelling of your feet or ankle? (edema)
- Do you feel palpitation or irregular heartbeats? Do you sometimes miss a beat? Do you feel dizzy? Have you suffered from blackout?
- Do you feel pain on your legs or arms during exercise or work? (intermittent claudication)
- Do your hands or feet become blue or cold?
Respiratory system:
- Do you suffer or ever suffered from difficulty in breathing? If yes, ask details (page nos 39 and 40).
- Do you have cough? If yes, ask details (see pages 38 and 39).
- Did you notice blood with your sputum? If yes, ask about the amount.
- Do you feel any chest pain? (If any, ask details page no. 37).
- Have you noticed any wheezing?
- Do you snore? Or, Did anyone complain that you snore during sleep?
- Do you have heartburn?
- Do you have pain or discomfort in your abdomen? If yes, ask details (page no. 36).
- Do you feel abdominal bloating or distension?
- How is your appetite? If any change, such as loss or increased appetite, ask details.
- Do you feel nausea or vomiting? If yes ask details (see page no. 41).
- Do you feel difficulty in swallowing? If yes, ask details (see pages 47 and 48).
- Do you have diarrhea or constipation? If any, ask details regarding duration, frequency, amount, aggravating factors, etc.
- Is there any recent change in bowel habit or alteration of bowel habit?
- Have you seen blood or mucus in stool?
- Did you notice black tarry stool? (melena)
- Do you have pale stool with itching and dark urine? (obstructive jaundice)
- Do you have any mouth ulcer?
Genitourinary system:
- Do you have frequency of micturition?
- Are you passing larger amount of urine? (polyuria)
- Do you get up at night to pass urine? (nocturia)
- Do you feel pain during passing urine? (dysuria)
- If your bladder is full, do you have to void it immediately? (urgency)
- Do you notice narrow stream while passing urine? (poor stream)
- Does the flow stop on straining for micturition?
- Do you notice difficulty in starting micturition? (hesitancy)
- Is there any dribbling at the end of micturition? (terminal dribbling)
- Do you have incontinence of urine?
- What is the color of your urine? Is it mixed with blood? (hematuria)
- Do you have any loin pain? If any, does it go from loin to groin?
- Have you any problem with your sex life?
- Did you notice any ulcer, rash or lumps on your genitals?
- (In female) Do you have any discharge from your vagina or urethra?
Nervous system:
- Do you suffer from headache? If yes, ask details (see page 43)
- Did you suffer from convulsion, fainting episodes, fits, blackout, vertigo or dizziness?
- Do you have problems with memory or concentration?
- Do you have trouble with your vision, hearing, taste or smell? Do you feel tinnitus?
- Do you have weakness (hemiplegia, paraplegia or monoplegia), tingling, numbness (pins and needles) or clumsiness in your arms or legs?
- Do you have tremor or any involuntary movement in any part of your body?
- Did you notice any problem with your balance?
- Did you ever have any head injury?
Locomotor system (musculoskeletal system):
- Do you have painful or stiff joints or swelling of joints? If yes, ask details (see pages 45 and 46)
- Do you have backache or pain in the neck or muscular pain?
- Do you feel weak or have difficulty in standing up from sitting position or difficulty in raising hands above your head?
- Have you noticed any skin rash? (dermatomyositis)
- Have you ever had a dry mouth or mouth ulcer?
- Have your eyes been dry or red?
Hematological system:
- Do you have bleeding from anywhere? Or bruise easily?
- Have you noticed prolonged bleeding after a small cut?
- Have you noticed any lump under your armpit or in your neck or groin? (lymph nodes).
- Have you ever had blood clots in your legs or other parts of the body? DVT (deep venous thrombosis).
- Do you feel extreme weakness, dizziness, lassitude, dyspnea, palpitation? (anemia).
- Are you taking any drugs? Have you been exposed to chemicals or radiation? (aplastic anemia).
Endocrine system:
- Are you suffering from diabetes mellitus or do you have any thyroid problem?
- Have you noticed any neck swelling?
- Do you prefer hot or cold weather? Do you have excessive sweating? (cold intolerance indicates hypothyroidism, heat intolerance with excessive sweating indicates hyperthyroidism)
- Do you have tremor in your hands?
- Do you feel weak or fatigue?
- How is your appetite? (excessive appetite occurs in diabetes mellitus and thyrotoxicosis. Loss of appetite in malignancy, CKD, CLD, tuberculosis, hypothyroidism)
- Have you lost or gained weight? (weight gain in hypothyroidism, Cushing syndrome. Weight loss in hyperthyroidism, Addison's disease, diabetes mellitus). Also remember, a patient with a good appetite but weight loss is found in thyrotoxicosis and diabetes mellitus. Weight loss with poor appetite is because of malignancy, CKD, CLD, tuberculosis.
- Is there any change in your appearance, hair, skin or voice?
- Do you feel unusually thirsty? (excessive thirst may be because of diabetes mellitus, diabetes insipidus, hypercalcemia, psychogenic).
Reproductive system (in females):
- Did you have any miscarriage or abortion?
- During your past pregnancy, did you suffer from high blood pressure or diabetes mellitus?
- In your previous delivery (if any), did you suffer from prolonged bleeding?
Other questions in female patients:
- Do you feel any lump in your breast? If yes, ask – For how long do you have this lump? Is it getting larger? Is it painful or painless? Is it associated with any discharge, itching or skin change?
DESCRIPTION (OR ELABORATION) OF SYMPTOMS
(What else to know from patient's complaints or symptoms)
Once a patient complains of a symptom, you should ask certain important related questions regarding that symptom to determine the exact nature of the problem. You should also ask related questions in order to localize the disease to a system or organ of the body, understand the nature of the involvement (e.g. inflammatory, neoplastic) and find out the cause.
Usual symptoms related to anatomical systems of the body:
- General symptoms—fever, weight loss, weight gain, weakness, sleep pattern, malaise, itching, skin rash, excessive sweating.
- Gastrointestinal system—abdominal pain, nausea, vomiting, loss of appetite, heartburn, dysphagia, constipation, diarrhea, hematemesis, melena.
- Hepatobiliary system—jaundice, pain in the right hypochondrium, hematemesis, melena, abdominal distension (ascites), itching.
- Cardiovascular system—central chest pain, dyspnea, palpitation, cough, leg swelling, chorea, bluishness.
- Respiratory system—cough, chest pain, dyspnea, hemoptysis.
- Rheumatological system—arthritis, arthalgia, soft tissue swelling, bony deformity, skin rash, extra-articular features.
- Nervous system—headache, convulsion, weakness, vertigo, parsthesia, loss of consciousness, speech disturbance, memory disturbance, involuntary movements.
- Genitourinary system—dysuria, frequency, urgency, polyuria, retention, incontinence, loin pain, swelling of leg, puffiness of face, urethral discharge, impotence, premature ejaculation, infertility, abortion, miscarriage, menstrual irregularity, pelvic pain.
- Endocrine system—weight loss or gain, sweating, cold or heat intolerance, palpitation, tremor, pigmentation, polyuria, polydipsia.
- Dermatology—rash, itching, ulceration, blister, swelling or mass, pigmentation or depigmentation.
- Hematological system—prolonged bleeding, pallor, weakness, swelling over neck, axial or inguinal area.
Remember that different diseases involving different systems of the body may present with different symptoms. Here only the few common symptoms have been described:
What to be asked? See as follows:
- How long have you been suffering from fever?
- When does it start (morning, evening, night, etc.)? How long does it persist (few hours or throughout the day or night)? Is there any evening rise of temperature associated with night sweats?
- What was the highest recorded temperature?
- Is it associated with chills and rigors? Does it subside with sweating?
- Does it subside spontaneously or with antipyretic? If there is spontaneous remission, ask about the length of each episode of fever and the duration of the intervening afebrile period. However, if there is no spontaneous remission, ask if the temperature fluctuate more than 2ºC or not more than 1ºC? (to find whether the fever is continuous, remittent or intermittent).
- Is the fever punctuated by apyrexial period? (Undulant or Pel-Ebstein).
- Is the fever associated with skin rash or purpura?
- Is there any other associated symptom? (urinary complain, cough, chest pain, pain abdomen, headache, impaired or loss of consciousness, weight loss, polyarthritis).
- Is there any history of sexual exposure, homosexuality, travel abroad?
- Are you taking any drugs? (to exclude any drug fever).
If the patient complains pain, ask (formula- SOCRATES):
- Site: Where is your pain?
- Onset: Was it gradual or sudden?
- Character: What is the nature of the pain? (dull ache, colicky, stabbing, compressive, crushing, agonizing, etc).
- Radiation: Does it radiate to anywhere?
- Association (e.g. nausea, sweating, fever, skin rash).
- Timing of pain or duration: How long are you suffering from this pain? When does it come and how long does it persist?
- Exacerbating factor and relieving factor.
- Severity: How severe is it?
If the patient complains of abdominal pain, ask:
- Site: What is the site of pain?
- Onset: Is it sudden or chronic? Does it disturb sleep at late night?
- Character: What is the character of pain?
- Radiation: Does it radiate to any site?
- Association: Is it associated with diarrhea, vomiting, dyspepsia, altered bowel habit, urinary complaints, gynecological complaints, abdominal distension, etc.?
- Timing and duration – How long have you been suffering from this pain? When does it start? When does it go? Has it changed since it has begun?
- Exacerbating and relieving factors – What brings it on? What makes it worse? Is it related to meal? What makes it better?
- Severity—How severe is it?
If the patient complains of chest pain, ask:
- Site: Where is your pain? (central or peripheral part of the chest)
- Onset: How did the pain start? (sudden or gradual)
- Character: What is the nature of pain? (compressive, sharp, tearing, stabbing)
- Radiation: Does the pain radiate to any site?
- Timing (duration): How long does it persist?
- Exacerbating factors: What causes the pain? What makes it worse?
- Relieving factor: How the pain is relieved?
- Severity: How severe is it? (mild, moderate, severe)
- Associated features: Is there any other associated features?
If the patient complains of cough, ask:
- How long have you been suffering from cough?
- Is it paroxysmal or persistent?
- Is it dry or productive?
- If productive of sputum, ask about its amount, color, odor, time of sputum production (morning), presence of blood and relation to posture change.
- Is it associated with hemoptysis? If yes, fresh or altered blood?
- Is it associated with chest pain, dyspnea?
- Is the cough aggravated by dust, cold air, smoke or pollen?
- Does it occur after eating or drinking?
- When does the cough get worse? (day or night).
- What is the character of cough?
- Are you taking any drug? (such as ACE inhibitor).
- Do you have diseases, such as rhinitis, asthma, heart disease, renal disorder?
If the patient complains of dyspnea or difficulty in breathing, ask:
- Is the onset sudden (acute) or gradual (chronic)?
- Does it occur with exertion or at rest?
- If exertional, how much activity causes breathlessness? (Mild, moderate and severe. Ask how far he can walk or how many stairs he can climb or if he can undress himself without feeling breathlessness).
- Do you get breathless at night that wakes you up from sleep (PND)? How do you feel better?
- Do you feel breathless on lying flat? (orthopnea). How many pillows do you use at night?
- Is it paroxysmal or progressive?
- Is there any seasonal variation with breathlessness?
- Is there any history of recent travel abroad by air?
- Do you smoke? If yes, number of sticks per day.
- Is there any aggravating factor or occupational exposure to coal dust, silica, asbestos, animal dander?
- Is there any relieving factor? (drugs, rest, change of posture, after expectoration of sputum, etc).
- Is it associated with other symptoms? (cough, chest pain, wheeze or hemoptysis)?
- Is there any history of respiratory or cardiac disease or allergy or renal failure?
If the patient complains of palpitation, ask:
- What do you really feel? (unexpected awareness of heartbeat)
- Did you check your pulse by yourself?
- How does it start? (spontaneous or with activity, anxiety, emotion, etc.)
- Is it paroxysmal or persistent?
- How long does it persist?
- How is it relieved?
- Have you ever missed a heartbeat?
- Do you get breathlessness, chest pain, dizziness or blackout with palpitation?
- Did it start with anorexia, nausea and vomiting?
- Any history of contact with jaundiced patient or sexual exposure?
- What is the color of the stool? (yellowish, pale, dark)
- Do you have itching?
- Did you ever take any injection, infusion or blood transfusion? (HBV or HCV)
- Any history of IV drug abuse, tattooing or surgery? (HBV or HCV)
- Do you take alcohol or any drugs (look for hepatotoxic drugs)?
- Is there any family history of jaundice, consanguinity of marriage among parents?
- Did you suffer from recurrent jaundice?
- Any associated history of high fever, urinary complaints?
- Previous history of jaundice associated with any neurological abnormality?
- Have you traveled abroad?
If the patient complains of headache, ask:
- What is the site of headache? (unilateral or diffuse, frontal, occipital or facial)
- What is the time of onset?
- How severe is it?
- What is the nature of headache? (throbbing, burning)
- How does it start?
- How long does it persist?
- Is it recurrent?
- Is there any aggravating factor, such as coughing, straining or change of posture?
- Is there any relieving factor?
- Is it preceded by any aura?
- Is it associated with fever, vomiting, weakness, blurring of vision, vertigo, nasal stuffiness, lacrimation, breathlessness?
- Are you taking any drug?
- Where have you been? (malaria endemic area)
- In female, ask about pregnancy (pre-eclampsia, especially if proteinuria and high blood pressure).
If the patient complains of joint pain, ask:
- Onset: Is it acute, gradual or chronic? Is it new or recurrent?
- Is there any history of trauma?
- How long are you suffering from joint pain?
- Is it associated with joint swelling?
- Which joints have been involved? Note the following:
- Number of joints involved (mono, oligo or polyarthritis)
- Symmetrical or asymmetrical.
- Distribution of joint involvement (small or large joint involvement).
- Upper or lower limb or both involvements.
- Does the pain move from one joint to other? (migratory or fleeting, additive)
- Does the pain worsen on activity or rest?
- Is there any morning stiffness? If present, how long does it persist? How does it subside? (improve with activity or exercise)
- Is it associated with redness, warmth and swelling? (suggest inflammation)
- Is there any deformity?
- Is there any extra-articular manifestation?
- Is this associated with dry mouth? (Sjogren syndrome)
- Do you have any skin or nail problem or is there any family history of such problem? (psoriatic arthritis)
- Is there any history of persistent bleeding?
- Is the arthritis preceded by urethritis, history of sexual contact, acute diarrhea (Reiter's syndrome, also may be eye problem)?
- Is there any history of frequent diarrhea? (IBD)
- Is there any history of tick bite in endemic area? (Lyme disease).
If the patient complains of dysphagia, ask:
- Can you show me with your finger at which level does the food get stuck?
- Is it due to solid or liquid or both?
- Is it painful or painless?
- Is it transient, intermittent or progressive?
- Do you have nasal regurgitation or cough during deglutition?
- Is it associated you heart burn or chest discomfort?
- Is there any difficulty to swallow?
- Did you notice bulging of the neck while eating or drinking?
- Is it generalized or localized?
- Distribution: Is it proximal or distal?
- Onset: Is it sudden or gradual?
- Progression: Is it ascending or descending?
- Does it worsen or improve with activity?
- Is there other features, such as muscle pain, skin rash, sensory loss, loss of bowel or bladder control?
- Do you take any drug or alcohol?
If the patient complains of weight loss, ask:
- How much weight did you lose? Over what period?
- How is your appetite?
- How is your bowel habit? (If frequent diarrhea or loose motion, ask details regarding color, amount, presence of blood, etc.).
- Do you feel excessively thirsty and micturate frequently?
- Do you have other symptoms, such as cough, fever, night sweat?
- Do you have palpitation?
- Do you prefer hot or cold environment?
- Do you feel that you are getting darker than before? (any change in your complexion?)
- Do you have vomiting? If yes, is it spontaneous or induced?
- Do you take alcohol or any other substance?
If the patient complains of weight gain, ask:
- How much weight did you gain? Over what period?
- How is your appetite?
- Do you feel weak or fatigue?
- How is your bowel habit?
- Do you prefer hot or cold environment?
- Do you take any drugs or alcohol?
- How is your menstrual cycle? Any growth of excessive hair? (For female).
- Do you have headache?
If the patient complains of vertigo, ask:
- Onset—is it sudden or gradual?
- Is it recurrent, persistent or progressively increasing?
- If recurrent, what is the frequency and duration?
- Do you feel that the surrounding is moving or do you feel yourself to be moving?
- What causes the vertigo? (movement of the head, standing from sitting position, traveling in a motor vehicle, anxiety, stress, menstruation, etc.).
- Does it relate to change in head posture?
- How severe is it?
- Did you ever suffer any head injury or trauma to the head?
- Is it associated with symptoms, such as hearing loss, tinnitus, headache, nausea, vomiting, pallor, sweating, double vision, frequent fall, ataxia, focal weakness, confusion or loss of taste sensation?
- Do you take any drugs? (aminoglycoside).
If the patient complains of swelling of the body, ask:
- Is it generalized, involving the whole body or localized to a part?
- If generalized, where did it first appear? (Face, feet, abdomen).
- If localized, is the swelling painful?
- What is the amount of urine you pass everyday? Is there any pain or burning?
- What is the color of your urine?
- Do you feel palpitation, cough, chest pain or breathlessness on exertion?
- Any history of sore throat or skin infection?
- Do you have diabetes mellitus or hypertension?
- Do you have cold intolerance, constipation, lethargy?
- Do you take any drugs? (steroid, amlodipine, nifedipine).
- How is your bowel habit?
- If the patient has cold intolerance ask, features of hypothyroid, such as weight gain, lethargy, increased sleepiness, constipation, etc.
- If patient has heat intolerance or excessive sweating, ask to exclude thyrotoxicosis, e.g. increased appetite, weight loss, palpitation, diarrhea, irritability.
If patient complains of polyuria, ask:
- What is the amount of water you take and void everyday?
- Are you suffering from diabetes mellitus?
- Is it associated with excessive thirst?
- Do you have excessive thirst with polyphagia?
- Are you taking any drugs? (diuretic, lithium, analgesic, cidofovir, foscarnet)
- Do you take alcohol or excessive coffee?
- Do you have excess thirst, abdominal pain, constipation, etc.?
- Do you have history of head trauma, pituitary surgery or stroke?
- (Take history of psychiatric illness).
If the patient complains of hematuria, ask:
- Is it at the beginning of micturition or at the end or throughout? (initial, terminal or total)
- Do you feel pain or burning during micturition? (dysuria)
- Is this associated with frequency, urgency or hesitancy?
- Do you have loin pain? Does it radiate to the groin? Do you have pain in lower abdomen or generalized abdominal pain? (If the patient complains of any pain, take detailed history as given in page 36).
- Have you noticed bleeding from any other part of the body?
- Do you have fever? (If yes, take detailed history of fever).
- Is it associated with nausea or vomiting?
- Have you noticed any rash? Is it associated with joint pain and swelling?
- Do you take any drugs? (anticoagulant, antiplatelet, analgesic, cyclophosphamide, antibiotic).
- Did you ever pass stones previously?
- Did you suffer from any kind of trauma?
- Did you suffer from skin infection or sore throat recently?
- Do you have hypertension, exertional breathlessness and swelling of the body?
- Is there any history of renal disease in your family?
- In female, enquire whether she is menstruating.
- Take occupational history specially looking for exposure to radiation or industrial chemicals like benzene.
- Have you recently traveled to any Middle Eastern country (to exclude bilharziasis or schistosomiasis)?