1. History and
2. Physical examination.

     

• Name:
• Age:
• Sex:
• Religion:
• Occupation:
• Address:
• Date of Admission:
• Date of Examination:
• Bed No. (Bed number allotted in the examination hall):

 

• Write the presenting complaint in chronological order with duration
• Do not write two symptoms in one sentence in chief complaint, e. g. pain in abdomen and jaundice for 2 years.

• Pain in right upper half of abdomen for– 2 years.
• Yellowish discoloration of eyes and urine for 2 years.

 

• Start with a comment that the patient was apparently well before this episode of illness which started (months/years) back. Avoid writing that patient was absolutely well or perfectly well—as patient may have some minor complaints earlier.
• Elaborate each chief complaint in one paragraph in history of present illness.
• If patient's chief complaints are pain, jaundice and vomiting, write details about pain, jaundice and vomiting in three different paragraphs maintaining the chronological order.
• Once the chief complaints are elaborated then write about other relevant symptoms.
• Symptoms pertaining to different systems should be asked and relevant symptoms are to be written.

 

• Pain
• Vomiting
• Hematemesis
• Heartburn
• Acidity
• Flatulence
• Sensation of fullness after meals
• Any sensation of rolling mass in abdomen
• Jaundice
• Appetite
• Weight loss
• Details of bowel habit—number of motions per day, consistency of stool, any change in bowel habit, any history of passage of mucus with stool, melena, bleeding per rectum.

 

• Any renal or ureteric colic
• Pain in loin
• Details of urinary habit
• Frequency, both diurnal and nocturnal
• Hematuria
• Pyuria
• Difficulty in passing urine
• Hesitancy and urgency.

 

• Chest pain
• Cough
• 3Hemoptysis
• Fever
  Breathlessness.

 

• Chest pain
• Palpitation
• Breathlessness on exertion
• Swelling of the face or feet
• Any history of paroxysmal nocturnal breathlessness associated with expectoration of pink frothy sputum.

 

• Headache
• History of loss of consciousness
• History of convulsion
• Any symptom pertaining to cranial nerve palsy
• Any history of loss of smell sensation
• Any difficulty in vision
• Any difficulty in eye movement
• Presence of squint
• Double vision
• Any difficulty in chewing
• Any loss of sensation in face
• Any loss of hearing
• Any difficulty in speech
• Any history of nasal regurgitation of food
• Any alteration of voice
• Any loss of taste sensation
• Any difficulty in tongue movement and wasting of tongue
• Any weakness in upper and lower limbs
• Any sensory loss.

 

• Do not write or say “nothing significant”
• Mention about any major medical ailment in the past
• Any history of operations. If so the type of operation, any postoperative complications. Any complications of anesthesia
• Any history of pulmonary tuberculosis (Koch's) in the past
• Any history of diabetes or hypertension which may be present earlier to this period
• Similar illness in the past. Particularly in disease characterized by relapse and remission.

 

• Marital status: Married or unmarried
• 4Number of children
• Status of health of spouse and children
• Dietary habit
• Any addiction: Cigarette, alcohol, beetel, tobacco chewing (addiction implies physical and mental dependence on a particular substance or drug and if denied that particular substance patient will have withdrawal symptoms.
  Otherwise mention these as habit of smoking or alcohol.
• Sleep
• Bowel habit/Bladder habit (To be mentioned here if not mentioned in the history of present illness). In an abdominal case, usually bowel and bladder habits are mentioned in history of present illness
• Socioeconomic status: Poor/average income/high income group

• Menstrual history
  • Age of menarche
  • Cycle
  • Duration of period
  • Amount of blood loss (assessed by number of pads used or if there is history of passage of clots)
  • Last menstrual period (mention the date)
  • In postmenopausal woman mention the time (months/years) of menopause
• Obstetrical history
  • Number of pregnancies (Mention as P_*+*)
  • Number of abortions
  • Number of live births: (i) Male and (ii) Female
  • Mode of delivery
  • Last child birth
  • Any complications following childbirth.

 

• Parents: If parents are alive, write their status of health. If parents are not alive, write when they had died and what was the disease he/she died of.
• Siblings: Number of brothers and sisters, and their status of health.
• In some hereditary diseases, e.g. carcinoma of breast, polyposis coli. Take history of 2–3 generations for similar disease or related diseases.

 

• Treatment received so far for the present disease
• Any other medications for other diseases.5

   

1. General survey: Quick overview of patient from head to foot.
2. Local examination and
3. Systemic examination

   

• Mental state: Conscious, alert, cooperative
• Performance status: Mention either in Karnofsky scale or ECOG scale
• Built
• Facies
• Gait
• Decubitus
• Hydration status
• Nutrition
• Anemia
• Jaundice
• Cyanosis
• Clubbing
• Edema
• Neck veins
• Cervical lymph node
• Pulse
• Blood pressure
• Respiration
• Temperature
• Any obvious deformity
• Any pigmentation

 

• Local examination of abdomen
• Local examination of breasts
• Local examination of inguinoscrotal region, etc.
• Write details of local examination, which will vary according to region being examined.

• Inspection
• Palpation
• Percussion (wherever applicable)
• Auscultation (wherever applicable).6

 

• Do not write systemic examination as “No abnormality detected”
• Better write in brief about each system.

1. Examination of Abdomen
   1. Inspection:
      • Shape of abdomen: Normal/obese/scaphoid/distended
      • Position of umbilicus: Central/deviated/pushed up/pushed down
      • Movements of abdomen: Respiratory/peristaltic/pulsatile
      • Skin over the abdomen: Any scar/pigmentation/venous engorgements
      • Any obvious swelling: Brief description of the swelling
      • Hernial sites: Any expansile impulse on cough
      • External genitalia
   2. Palpation:
      • Superficial palpation
        • Temperature
        • Tenderness
        • Any muscle guard
        • Any swelling
      • Deep palpation
        • Any tenderness in any of the deep tender spots
        • Any other sites of tenderness
        • Palpation of liver/spleen/kidneys
        • Deep palpation of any swelling
        • Fluid thrill
   3. Percussion:
      • General note over abdomen
      • Shifting dullness
      • Upper border of liver dullness
      • Upper border of splenic dullness
      • Percuss over the renal angle area.
   4. Auscultation:
      • Bowel sounds
      • Any added sound
   5. Per-rectal examination :
   6. Per-vaginal examination (if applicable):
2. Examination of Respiratory System
   1. Inspection:
      • Respiratory rate
      • Shape of chest
      • Movement of chest
   2. Palpation:
      • Position of trachea
      • 7Tenderness over the chest
      • Movement of chest
      • Vocal fremitus
   3. Percussion:
      • Note over chest
   4. Auscultation:
      • Breath sound
      • Any added sound: Crepitation/Rhonchi
      • Vocal resonance
3. Examination of Cardiovascular System
   • Inspection:
     • Shape of precordium
     • Apex beat
     • Any pulsation
   • Palpation:
     • Apex beat.
     • Left parasternal heave
     • Any thrill
   • Auscultation:
   • 1st/2nd heart sound
   • Any murmur
   • Any gallop.
4. Examination of Nervous System
   • Higher functions:
     • Conscious, alert, cooperative
     • Speech: Normal/any special character
     • Cranial nerve: I to XII. Any palsy
   • Motor system:
     • Tone, power, coordination of upper limb
     • Tone, power, coordination of lower limb
   • Sensory system:
     • Superficial sensation: Pain, touch, temperature
       • Face, neck
       • Upper limbs
       • Trunk
       • Lower limbs
     • Deep sensation
       • Joint sensation
       • Vibration sense
     • Deep reflexes: Jerks
     • Superficial reflexes
       • Abdominal reflex
       • Plantar response
     • 8 Cerebellar sign: Absent
     • Gait: Normal
5. Examination of Cranium and Spine
   • Normal

   

• This is a case of carcinoma of the left breast T2N1M0 (stage II) in a premenopausal woman
• This is a case of obstructive jaundice probably due to carcinoma of head of the pancreas.

 

• Investigations for confirmation of diagnosis
• Investigations to stage the disease (in case of a malignant disease)
• Investigations to assess fitness of patient for anesthesia and surgery.

• Base line investigations
  • Blood for hemoglobin, total leukocyte count (TLC), differential leukocyte count (DLC) and erythrocyte sedimentation rate (ESR)
  • Blood for sugar, urea and creatinine
  • Urine for routine examination
  • Stool for routine examination for ova/parasite/cyst
  • Chest X-ray (posteroanterior view)
  • 12-lead electrocardiogram.
• Special investigations
  • Depends on the provisional diagnosis.

 

• Write few relevant differential diagnoses. In list of differential diagnosis the more probable diagnosis should be written before the rare diagnosis.

• If the examiner asks you what is your diagnosis. Then straightway give a complete diagnosis.9

 

• The Eastern Coopeartive oncology group (ECOG) performance status is as follows:
  Performance scale:
  • 0: Fully active and is able to carryout normal activities without any restriction.
  • 1: Symptoms restrict strenuous activity but is able to carryout light sedentary activities.
  • 2: Ambulatory but unable to carryout normal activities.. Up and about >50% waking hours.
  • 3: Only limited self care. Confined to bed for >50% of waking hours.
  • 4: Completely confined to bed, disabled, needs assistance.
  So ECOG performance status is written as.. score of 0, 1, 2, 3 or 4.
• Karnofsky scale for performance status is as follows:
  • Able to carry on normal activity and to work; no special care needed (100–80).
    • 100: Normal no complaints; no evidence of disease.
    • 90: Able to carry on normal activity; minor signs or symptoms of disease.
    • 80: Normal activity with effort; some signs or symptoms of disease.
  • Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed (70–50).
    • 70: Cares for self; unable to carry on normal activity or to do active work.
    • 60: Requires occasional assistance, but is able to care for most of his personal needs.
    • 50: Requires considerable assistance and frequent medical care.
  • Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly (40–0).
    • 40: Disabled; requires special care and assistance.
    • 30: Severely disabled; hospital admission is indicated although death not imminent.
    • 20: Very sick; hospital admission necessary; active supportive treatment necessary.
    • 10: Moribund; fatal processes progressing rapidly.
    • 0: Dead

• Look at tongue and oral mucosa—Normally moist. In case of dehydration will appear dry.
• Pull the skin and release. Normal skin is elastic. In case of dehydration, the skin turgor will get lost (Figs 1.3A and B).
• Patient will feel thirsty and urine output will also diminish.

• Calculating the body mass index.
• Assessing the thickness of the subcutaneous fat in the arm, forearm or the back (Fig. 1.4A)
• Assessing the bulk of the muscle by measuring the mid upper arm circumference (Figs 1.4B and C)
• Look for any evidence of vitamin deficiency: skin changes (dermatitis), stomatitis, glossitis (Fig. 1.4D), etc.

• Body mass index = Weight in kg/Height in sq meter.
  • Body weight—60 kg, height—1.5 metre.
  • 13Body mass index (BMI) + 60/2. 25 = 26. 6
  • Depending on the body mass index patient may be classified as:

    Underweight	:	BMI—<18. 5
    Normal	:	BMI—18. 5–24. 9
    Overweight	:	BMI—25–29. 9
    Obese	:	BMI—30 or higher

  • Nutritional state is described as poor, average or overnutrition.
  • In practical examination it may not be possible to measure BMI, unless you have a weighing machine and a height scale.

• Mild anemia: When the hemoglobin is 50–60% of the normal
• Moderate anemia: When the hemoglobin is 40–50% of normal
• Severe anemia: When the hemoglobin is less than 40% of normal.

• In deep jaundice there is yellowish hue of general body skin surface. Jaundice is also looked in general body skin surface, palms and soles
• 15Normal bilirubin: Serum bilirubin value of 0. 2–0. 8 mg%
• Latent jaundice: Serum bilirubin between 1 mg% 1. 9 mg%
• Clinical jaundice is seen when the bilirubin level is more than 2 mg%.

• Peripheral cyanosis: Arterial oxygen saturation is normal but there is more oxygen desaturation at the veno-capillary bed. This may be due to peripheral vasoconstriction or sluggish circulation
• Central cyanosis: This is due to excessive oxygen desaturation of the arterial blood.

• Look at the nail from the side to look for increased curvature of the nail (Fig. 1.8A) and assessment of angle between the nail and nail bed
• Look for fluctutation at the base of the nail with two index fingers (Fig. 1.8B).
• Look for Schamroth sign (Fig. 1.8C).

• Superficial: Lymph nodes lying superficial to the investing layer of the deep cervical fascia
• Deep: Lymph nodes lying deep to the investing layer of deep cervical fascia
• These lymph nodes may further be subdivided into horizontal chain and vertical chain.

• Level IA lymph nodes are palpated at the submental triangle with the pulp of the fingers directed upwards with the neck slightly flex and turned to the same side (Fig. 1.15A)
• Similarly level IB nodes are palpated at the submandibular triangle (Fig. 1.15B)
  

  Figure 1.15A: Palpation of level IA (submental group) lymph node
  

  Figure 1.15B: Palpation of level IB (subman­dibular group) lymph nodes
• Level II, III and IV nodes are palpated along the line of internal jugular vein with the pulp of the fingers (Figs 1.15C to E)
• Level V nodes are palpated at the posterior triangle with the pulp of the fingers (Figs 1.15F and G)
• The supraclavicular nodes (Level V) are palpated with the pulp of the fingers kept at the supraclavicular fossa and asking the patient to shrug the shoulder up (Fig. 1.15H)
• Level VI nodes are palpated at the pre- and paralaryngeal and tracheal region.

• Normal heart rate: It is 60–100 beats per minute, average 72 beats per minute
• Bradycardia: Heart rate less than 60 beats per minute
• Tachycardia: Heart rate more than 100 beats per minute
• Relative bradycardia: When there is fever, there is rise of pulse rate. for each degree rise of temperature and there is rise of 10 beats per minute. When with per degree rise of temperature, the pulse rate increase is less than 10 beats per minute then it is called relative bradycardia, e. g. enteric fever (1st week)
• Relative tachycardia: With per degree rise of temperature, the pulse rate rise is more than 10 beats per minute, e. g. rheumatic carditis.

• Normal rhythm: The successive pulse beats are appearing at definite intervals
• Irregular rhythm: The successive pulse beats are not appearing at definite interval. This may be
  • Irregularly irregular
  • Successive beats are appearing at irregular intervals or the rhythm may be occasionally interrupted by a slight irregularity coming at definite interval
  • Regularly irregular.

• Normal body temperature: 98–99°F
• Subnormal temperature: Below 98°F
  

  Figure 1.19: Types of fever
• 24Pyrexia: Above 99°F
• Hyperpyrexia: Above 106°F
• Hypothermia: Below 95°F.

• Continuous fever: The daily fluctuation of temperature is less than 1. 5°F and the temperature does not touch the baseline. It is found in pneumococcal pneumonia, in second week of enteric fever and rheumatic fever
• Remittent fever: The daily fluctuation is more than 2°F and the temperature does not touch the baseline. This is found in urinary tract infection and pulmonary tuberculosis
• Intermittent fever: Fever continues for several hours and returns to normal during the day. This may be:
  • Quotidian: The paroxysm of intermittent fever occurs daily
  • Tertian: The paroxysm of intermittent fever occurs on alternate days
  • Quartan: The paroxysm of intermittent fever occurs every three days
  • Relapsing fever: There cyclic periods of fever and periods of apyrexia.

   

• Duration: How long is the swelling present?
• Site: Where was the swelling first noticed?
• Mode of onset: Whether swelling appeared following trauma, or developed spontaneously.
• Progress of swelling:
  • Static: Same as onset, no increase in size
  • Slowly increasing in size since beginning (usually benign swelling)
  • Rapidly increasing in size since beginning (usually malignant)
  • Initially slowly increasing in size, later (after a variable period) started rapidly increasing in size (benign swelling showing malignant change)
  • Initially increasing size. Later the swelling regressed with time or treatment (inflammatory)
  • Ask the patient what was the size of the swelling when he first noticed it. Earlier this was described as either pea, marble, lemon or orange shaped. It is better to describe the approximate size of the swelling in cm at the onset. From patient description try to assess the approximate size of the swelling at onset and describe as… the swelling was about 2 cm/3 cm/4 cm…. in size at the onset and then describe the progress of the swelling.
• Pain over the swelling:
  1. Duration of pain
  2. Site of pain
  3. Character of pain
  4. Any radiation of pain
  5. Periodicity of pain
  6. Relation of pain with the swelling
• Any other swelling in the body
• Any history of fever, loss of appetite, loss of weight
• Any subsequent changes over the swelling, e. g. ulceration, satellite nodules. Ask when these changes were first noticed
• In a suspected malignant disease enquire about symptoms which will suggest metastasis, chest pain, cough, hemoptysis, bone pain, headache, vomiting, loss of consciousness, convulsion, pain abdomen, abdominal distension and jaundice
• Any history of previous excision of the swelling and recurrence
• History of similar swelling in the past
• Any history of tuberculosis

     

• Number
• Site
• 26Extent
• Shape
• Size
• Surface
• Margin
• Skin over the swelling
  • Scar
  • Venous prominence
  • Pigmentation
  • Ulcer, any discharge
  • Peau d'orange
  • Satellite nodule
• Impulse on cough (For hernias and men­ingocele)
• Any pressure effect
  • Swelling of limbs
  • Muscle wasting

• Temperature
• Tenderness
• Site
• Extent
• Shape
• Size
• Surface
• Margin
• Consistency
• Fluctuation, if the swelling is cystic
• Transillumination, if swelling is cystic
• Reducibility:
  • Reducible or not
• Compressible or not
• Palpable impulse on cough
• Fixity of the swelling to skin
• Fixity of the swelling to deeper structure
  • Muscle: Test mobility with muscle relaxed and contracted
  • Tendon: Test mobility with tendon relaxed and after tendon is made taut with contraction of muscle
  • Bones: Swelling is fixed as such
  • Vessel compression effect: Absence of pulse distal to the swelling
  • Nerve compression effect: Test for muscle power and sensation
• Pulsation: If present, transmitted or expansile pulsation
• Any thrill on palpation
  Percussion
• Auscultation
  Movement of adjacent joint
  Examination of regional lymph nodes 27

 

• Soft (Feel of a relaxed muscle) or
• 29Firm (Feel of a contracted muscle).
• Hard (Feel of bone).
• The consistency of a swelling may be described as variegated when the swelling has a variable feel soft, firm or hard at different parts of the swelling.

• Vaginal hydrocele
• Cystic hygroma
• Encysted hydrocele of the cord
• Hydrocele in the canal nuck
• Congenital hernia in infants may show positive transillumination.

   

• Duration: For how long ulcer is present
• Mode of onset: Following trauma or spontaneously or following a swelling
• Site: Where first noticed
• Progress of the ulcer: Change in size and shape
• Any pain over the ulcer: Site of pain, any radiation, character of pain and severity.
• Any discharge: Serous/purulent/hemorrhagic
• Any associated disease: Diabetes/sickle cell anemia/pulmonary tuberculosis/varicose vein/systemic malignancy/AIDS
• Past history of similar ulcer, any history of tuberculosis in the past
• Personal history: enquire about smoking, alcohol intake.

     

• Number
• Site: Describe in relation to the region or bony landmark.
• Extent
• Shape: Circular, oval, irregular or serpiginous
• Size
• Margin (Fig. 1.35): This is the junction of normal skin and the periphery of the edge of the ulcer.
• Edge of the ulcer: Area of the ulcer between the floor and the margin. The edge may be (Fig. 1.36):
  • Sloping
  • Undermined
  • Punched out
  • Sloping
  • Raised and rolled out
  • Raised and beaded
• Floor of ulcer: Exposed portion of the ulcer. Floor may be covered by red granulation tissue/pale granulation tissue/slough
• Discharge character, amount, smell
• Adjacent area:
  • Any swelling
  • Any skin change
  • Any secondary changes, pigmentation, pallor.
  • Any associated venous diseases

 

• Temperature: Palpate the area adjacent to the ulcer for any rise of local temperature
• Tenderness: Over the ulcer and adjacent area
• Size of the ulcer: Measure with a tape from one margin to the other.
• Margin and edge of ulcer: Type, any induration
• Base: The area on which ulcer rests (Fig. 1.36) (Feel the base by picking up the ulcer in between the thumb, index and middle finger)
• Test mobility of ulcer over the deeper structure
• Any discharge during palpation: Bleeding or mucus discharge

   

• Precceding history of swelling, pain and fever.
• History of discharge:
  • Type of discharge(purulent, mucus, bilious, feculent or urine), any discharge of bony spicules (may suggest underlying osteomyelitis)
  • quantity of discharge, color and odour.
  • Progress: Sometimes discharge may stop and opening may be blocked. Recollection occurs in the tract and discharge comes out through the same or a different opening.
• Any history of pain.
• History of fever.

       

• Site of fistula.
• How many external openings: Single or multiple?
• Appearance of external opening: Any presence of granulation tissue, margin of the opening.
• Any discharge from the opening: Character of discharge and the odour of discharge.
• Appearance of the area adjacent to the external opening: Any swelling, any scar, pigmentation.

 

• Temperature of the local area.
• Tenderness around the site of external opening.
• Palpate the wall of the tract: Any thickening.
• Palpate for any swelling adjacent to the sinus/fistula.
• Palpate for any bone thickening adjacent to the external opening (Bone thickening found in osteomyelitis).
• In case of perianal fistula—rectal examination to assess the presence of internal opening.
• In case of vesicovaginal or rectovaginal fistula—Per vaginal examination.