Second Edition
Rano Mal Piryani MBBS MCPS DTCD MD Fellowship in Medical Education
Professor and Head, Internal Medicine and Medical Education Director, Health Professionals Education and Research Center Chitwan Medical College
Bharatpur, Nepal
Suneel Piryani MBBS
Institute of Medicine Tribhuvan University
Kathmandu, Nepal
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History Taking and Clinical Examination Pattern at a Glance (For Undergraduates)
First Edition: 2009
Reprint: 2011
Second Edition: 2015
9789351526193
Printed at
5Dedicated to
Our beloved parents for their eternal love, care, support and blessings.
We believe parents are the first Gurus of child
7Preface to the Second Edition
The technology of medicine continues to evolve and the subject of medicine is fast changing in 21st century but the learning of core skills of communication, history taking, clinical examination, objective assessment, reasoning, diagnosis and planning relevant investigations and management are as essential to clinical practice as ever.
The first edition of the book was published in 2009 with the intention to facilitate undergraduate students of medicine to have a ready-reference about history taking and clinical examination for all clinical subjects being taught during undergraduate study in most of the medical schools. The reprint of the first edition was brought out in 2011.
In the light of feedback received from the users, we have revised and updated the book. In this new edition, we have divided the content into eleven sections. is new addition which focuses on general guidelines about learning communication skills, history taking skills and clinical examination skills and recording and presenting clinical notes. While to are on specific subjects. Chapters in these sections have been elaborated and updated.
We request the readers to forward any comment(s) or suggestion(s) on the second edition of History Taking and Clinical Examination Pattern at a Glance (For Undergraduates) to us or publisher.
We hope the book will be useful for learning basic core skills in medicine at undergraduate level.
We welcome positive and constructive criticism.
Rano Mal Piryani
Suneel Piryani
9Preface to the First Edition
History Taking and Clinical Examination Pattern at a Glance (For Undergraduates) is compiled with the intention to facilitate undergraduate students to have a ready-reference about history taking and clinical examination for all clinical subjects being taught during undergraduate study in most of the medical colleges. This is a sort of checklist, help to prepare for examination. For more detail information, student has to refer various books written by well-known authors on History Taking and Clinical Examination, some of them are mentioned in bibliography of this book. There may be some deficiencies in this book; users' input will help us in bringing out the subsequent editions. Suggestions can be sent through email (r_piryani@yahoo.com or suneel.piryani@gmail.com).
We indebted to Dr SS Hiremath, Associate Professor and Head, Department of Dentistry, KIST Medical College, Nepal, for providing input on dental section, and Professor Bidya Dev Sharma, Head, Department of Psychiatry, Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal.
We wish to thank Dr Ashish Lohani (Intern TUTH), Dr Rashmi Malhotra (Intern TUTH), Dr Suresh Nepal (Intern TUTH) and Dr Suresh Subedi (Intern TUTH), who have given their constructive suggestions.
We acknowledge the authors and editors whose books and formats are referred for the book.
Rano Mal Piryani
Suneel Piryani
11Acknowledgments
We acknowledge the users of first edition for their feedbacks and suggestions.
We are indebted to the authors and editors whose books and formats were referred for updating the second edition.
We wish to thank M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India, for their willingness to publish the second edition.
We express our heartfelt thanks to all our teachers, students, and patients who have taught us so much about medicine.
15Abbreviations
a/c
According
AC
Air Conduction
Ant.
Anterior
AOM
Acute Otitis Media
Approx.
Approximate
APH
Antepartum Hemorrhage
AR
Aortic Regurgitation
ARM
Artificial Rupture of Membrane
ASIS
Anterosuperior Iliac spine
AV
Arteriovenous
a/w
Associated with
BC
Bone Conduction
BCG
Bacillus Calmette-Guerin
B/L, b/l
Bilateral
BP
Blood Pressure
BPH
Benign Prostate Hypertrophy
bpm
Beats Per Minutes
b/w
Between
C
Cervical
C/C
Chief Complaints
ca
Carcinoma
cm
Centimeter
CN
Cranial Nerve
CNS
Central Nervous System
COPD
Chronic Obstructive Pulmonary Disease
CS
Cesarean Section
CSOM
Chronic Suppurative Otitis Media
16CVS
Cardiovascular System
DDH
Developmental Dysplasia Hip
DM
Diabetes Mellitus
DNS
Deviated Nasal Septum
DPT
Diphtheria Pertussis Tetanus
ds
Disease
d/t
Due To
DVT
Deep Venous Thrombosis
EAC
External Auditory Canal
EDD
Expected Date of Delivery
e.g.
For Example
ENT
Ear, Nose and Throat
EPI
Expanded Program of Immunization
ET
Eustachian Tube
etc.
Et cetera
FB
Foreign Body
FHS
Fetal Heart Rate
FNAC
Fine Needle Aspiration Cytology
ft
Feet
G
Gravida
GB
Gallbladder
GCS
Glasgow Coma Scale
GDM
Gestation Diabetes Mellitus
GI
Gastrointestinal
gm
Gram
Hg
Mercury
HIV
Human Immunodeficiency Virus
H/o or h/o
History of
hrs
Hours
HRT
Hormone Replacement Therapy
Ht
Height
17HTN
Hypertension
Hz
Hertz
IAP
Indian Association of Pediatrics
ICS
Inter-Costal Space
i.e.
that is
IOP
Intraocular Pressure
IV
Intravenous
JE
Japanese Encephalitis
JVP
Jugular Venous Pressure
Kcal
Kilocalorie
Kg
Kilogram
L
Lumbar
LMN
Lower Motor Neurone
LMP
Last Menstrual Period
LN
Lymph Node
LSCS
Lower Segment Cesarean Section
Lt or lt
Left
m
Meter
MAL
Mid-Axillary Line
MCL
Mid-Clavicular Line
mg
Milligram
MI
Myocardial Infarction
min
Minute
mm
Millimeter
mths
Months
MUAC
Mid Upper Arm Circumference
O2
Oxygen
Obs/Gynae
Obstetrics/Gynecology
OE
Otitis Externa
OME
Otitis Media with Effusion
OPD
Out Patient Department
18OPV
Oral Polio Vaccine
P
Para
PID
Pelvic Inflammatory Diseases
PIH
Pregnancy Induced Hypertension
PND
Postnasal Drip
PNS
Para-nasal Sinuses
Post
Posterior
PPH
Postpartum Hemorrhage
PR
Per Rectum
Pt or pt
Patient
PV
Per Vaginam
RA
Rheumatoid Arthritis
RAPD
Relative Afferent Pathway Defect
R/R
Respiratory Rate
Rt or rt
Right
S
Sacral
S1 S2 S3 S4
First, second, third and fourth heart sounds
SFH
Symphysis Fundal Height
S/he
She or he
SLE
Systemic Lupus Erythematosus
SLRT
Straight Leg Raising Test
STD
Sexually Transmitted Diseases
STI
Sexually Transmitted Infection
T
Thoracic
TB
Tuberculosis
TM
Tympanic Membrane
TMJ
Temparomandibular Joint
TT
Tetanus Toxoid
UB
Urinary Bladder
U/L, u/l
Unilateral
USG
Ultrasonograph
19Usu
Usually
UTI
Urinary Tract Infection
w/
With
WHO
World Health Organization
w/o
Without
wks
Weeks
Wt
Weight
yr or yrs
Year or Years