INTRODUCTION A student while posted in medicine has to learn the clinical medicine with following aims: 1 . One should learn the art of taking a detailed informative history. History taking is an important aspect of medicine. 2. One has to know the method of detailed physical examination to be carried out. Both the important positive and negative physical signs are to be noted so as to reach some conclusion at the end of examination. 3. The exact terminology used in medicine has to be followed. Terminology based on science is the foundation for the solution to many clinical problems. 4. The practice of medicine combines both science and art. The dazzling advances in biochemical methodology and in biophysical imaging techniques that allow access to the remotest recesses of the body are the products of science. So, too are the therapeutic manoeuvres which increasingly are major products of medical science. One has to learn the skill in the most sophisticated application of laboratory technology or use of the latest therapeutic modality. 5. The ability to extract items of crucial significance from a mass of contradictory physical signs and from the printouts of laboratory data, when a clinical sign is worth pursuing or when to dismiss it as red herring and to estimate in any given patient whether a proposed treatment entails a greater risk than the disease are all involved in the decision-making. This combination of medical knowledge, intuition and judgement is termed the art of medicine, which one has to learn. 6. The patient-doctor relationship : It may be emphasised that students/physicians need to approach patients not as cases or diseases but as individuals whose problems/symptoms are to be heard sympathe- tically. Most patients are anxious and frightened. Often, they go to extreme ends to convince themselves that illness does not exist or unconsciously develop false belief or perception about benign disease as life threatening illness. Some patients may use illness to gain attention, or to serve as a crutch to extricate themselves from an emotionally stressful situation; some even feign physical illness. Without this knowledge, it is difficult for the physicians to gain rapport with the patient or to develop insight into the patients illness. The patient-doctor relationship must be based on thorough knowledge of the patient and on the mutual trust and the ability to communicate with one another. A strong personal relationship with the patient is essential in order to sustain the patient during stressful situation. HISTORY TAKING The Skills The written history of a patient should contain all the facts of medical significance in the life of the patient. The history should be recorded in a chronological order. The recent events should be given most attention. A problem-oriented approach should be adopted while recording the history; the problems that are clinically dominant should be listed first. Ideally, patient should be allowed to narrate his/her history in his/her own way and language without any interruption. However, few patients have sufficient power of observation or recall to give a history without some guidance from the physician. A physician/student must be careful not to suggest the answers to the questions being posed. A physician/student should hear the history with patience, often a symptom which has concerned a patient most may have little significance, while an apparently minor complaint may be of considerable importance.

18 Clinical Methods in Medicine ANALYSIS OF SYSTEMIC SYMPTOMS The symptoms pertaining to various systems have been briefly described in Review of Systems. These systemic symptoms are analysed with respect to their causes, pathogenesis, clinical significance and their relevance. Gastrointestinal symptoms (Box 2.1) Box 2.1: S YMPTOMS RELATED TO GI TRACT Pain abdomen Dysphagia Dyspepsia or Flatulence Diarrhoea Heart burn Constipation Anorexia Bleeding per rectum Vomiting Abdominal distension Pain Abdomen 1. Duration and pattern of pain help to determine the nature and severity of pain. Abdominal colicky pain is acute severe crampy pain during which patients cry in discomfort or toss in the bed. Mid-line pain is usually visceral pain due to distention of a hollow viscus and localises poorly. Pain around the umbilicus is usually due to intestinal diseases, e.g. acute intestinal obstruction. Somatic pain (due to peritoneal involvement) is usually sharper and is localised to the diseased region, e.g. right iliac fossa in appendicitis, right hypochondrium due to stretching of capsule of liver in acute hepatomegaly and to the loin in renal disorders. The causes of pain in different abdominal quadrants are given in the Fig. 2.1. Radiation of pain: Pain originating from specific organs radiates to the specific sites, i.e. to right shoulder (in hepatobiliary diseases and diaphragmatic pleurisy), to left shoulder (splenic disease), to mid-back (pancreatic disease), to the flank (urinary tract disease) and to the groin (genitourinary tract diseases). Precipitating and relieving factors: The aggravating or relieving factors in relation to various diseases, are given in the Box 2.2. Anal ysis of Systemic Symptoms 2 Fig. 2.

Chapters 3 . G eneral Physical Examination 4 9 - 6 0 4 . The Head, Scalp, Skin and Hair 6 1 - 8 0 5 . The Eyes 8 1 - 1 0 0 6. The Mouth and the Pharynx 101 - 109 7 . The Ear , Nose, Sinuses and Throat 110 - 121 8. The Neck 122 - 130 9 . The Breast and the Axillae 131 - 138 1 0 .

The Head, Scalp, Skin and Hair 61 HEAD AND SCALP Applied anatomy and physiology Regions of the head derive their names from the underlying bones of the skull (e.g. frontal, parietal, temporal and occipital area), knowledge of anatomy helps to locate and describe the clinical findings. Common presentations Headache Abnormalities of the skull Hydrocephalus History Headache is an extremely common complaint that always requires careful evaluation, since a small fraction of headache arise from life-threatening conditions. Ask about the following attributes of headache: 1 . Location: Where is it Does it radiate Is it unilateral or bilateral 2. Quality: What is it like Is it steady or throbbing Is it continuous or comes and goes 3 . Severity: How severe is it 4 . Timing: When did (does) it start How long did (does) it lastHow often did ( does) it comeDoes headache recur at the same time everyday 5 . Setting in which it starts include enviornmental factors, personal activities, emotional reactions or other contributory circumstances. 6 . Aggravating or relieving factors: Does anything make it better or worst Ask whether coughing, sneezing or changing the position of the head have any effect (better, worse, or no effect ) on headache. 7. Associated symptoms: Have you noticed anything else that accompanies it such as nausea, vomiting and neurological symptoms such as change in vision or motors/sensory deficits Examination The scalp: Separate the hairs at several places and look for scaliness, naevi or other lesion. Redness and scaling occurs in seborrhoeic dermitits and psoriasis. The skull (cranium): Note the size and contour. Look for any deformity, depression, lump or tenderness. The abnormalities are given in the Box 4.1. Some children may have larger head than normal according to his/her age (Fig. 4.1) Common clinical conditions related to cranium Headache: It means all aches and pains localised to head. It is a common symptom of a variety of both benign and malignant conditions, hence, carries dual significance and keeps the physicians alert. Fortunately, in most circumstances, it is benign either due to tension or fatigue and is reversible. T he Head, Scalp, Skin and Hair 4 Box 4.1: A BNORMALITIES OF SKULL Anencephaly means Microcephaly refers to small Macrocephaly or Localised bony bossing is absence of cranial vault, cranium and brain. It is seen large skull is seen in seen over meningioma. scalp and cerebral hemis- as a part of many syndromes hydrocephalus (Fig. 4.2A). Skull tenderness is seen pheres. The brain is and also secondary to There is enlargement of following trauma or temporal a compact mass of premature closure of the skull in Pagets disease. arteritis. neurones, glial cells, cranial sutures. Encephalocoele (Fig. 4.2B) nerve fibres and blood refers to failure of midline vessels. d e f ect resulting in evagination of brain tissue outside the skull.

The Eyes 81 THE E YES (FIG. 5.1) Applied anatomy and physiology The organs of vision are the eyes. Each eye is situated in the orbita bony cage. It consists of upper and lower eyelids, the upper eyelid covers a portion (one-eighth) of the cornea but does not overlap the pupil. The space between the two-eyelids is called palpebral fissure. The white colour of sclera on the sides of the cornea looks somewhat buff-coloured at its extreme periphery. Do not confuse this colour for jaundice, which is deeper yellow. The conjunctiva is a clear mucous membrane with two visible components. The first component, the bulbar conjunctiva covers most of the anterior eye ball adhering loosely to the underlying tissue. It meets the cornea at the limbus. The other component, the palpebral conjunctiva lines the eyelids. The two parts/components merge in a folded recess that permits the eyeball to move. Within the eyelids lie tarsal platesfirm strips of connective tissue. Each plate contains a parallel row of meibomian glands , which open on the lid margin. The levator palpebrae superioris muscle raises the upperlid and is innervated by 3rd cranial nerve. Smooth muscle innervated by the sympathetic nervous system also contributes to raising this lid. This is the reason that the upper lid droops both in 3rd nerve and sympathetic paralysis (Horners syndrome). A clear fluid called tear fluid protects the conjunctiva and cornea from drying, has anti-microbial action and gives a smooth optical surface to the cornea. This fluid comes from three sources, i.e. meibomian glands, conjunctival glands, and the lacrimal gland. The lacrimal gland lies within the orbit, above and lateral to the eyeball. The tear fluids after spreading through the eye drains into lacrimal sac and further into the nose through nasolacrimal duct. The eyeball is a spherical structure that focusses light on the retina. The size of the pupil is controlled by the muscles of the iris. Muscles of the ciliary body control the thickness of the lens allowing the eye to focus on near or distant objects. The aqueous humour a clear fluid produced by the ciliary body, circulates from the posterior chamber through the pupil to anterior chamber, and drains out through the canal of Schlemm . The circulatory system helps to control pressure inside the eye (intraocular tension). The posterior part of the eye that is seen through an ophthalmoscope is often called the fundus of the eye. Structures here include the retina, choroid, fovea, macula, optic disc and retinal vessels. The optic nerves with retinal vessels enters the eyeball at optic disc. Lateral and inferior to the disc, there is a dark circular area with a central depression-called fovea centralis , marked for central vision. The fovea is surrounded by macula which does not reach the optic disc. The eyeball behind the lens is filled by a transparent gelatinous materialcalled vitreous body that maintains the shape of the eye. T he Ey es 5 Fig. 5.

The Mouth and the Pharynx 101 THE MOUTH AND THE PHARYNX (FIG. 6.1) The mouth is an open cavity. The lips are muscular folds that form the opening of the mouth. When mouth is opened, the gums (gingivae) and teeth are visible. Note the scalloped shape of the gingival margins and the pointed interdental papillae. The gingiva is firmly attached to the teeth and to the bone (maxilla or mandible) in which they are seated. In the lighter- skinned people, the gingiva is pale to coral pink and lightly stippled; while in darker-skinned persons, it may be diffusely or partly brown. A midline fold called labial frenulum connects each lip with the gingiva. Each tooth, composed mostly of dentine, lies rooted in a bony socket with only its enamel-covered crown exposed. Small blood vessels and nerves enter the teeth though its apex and pass into the pulp. The adult has 32 teeth (16 in each jaw). Each half of upper and lower jaw, thus, has 8 teeth (2 incisors, one canine, two premolars and 3 molars). The dorsum of the tongue is covered with papillae giving it a rough surface. Some of these papillae look like red dots on the thin white coat that often covers the tongue. The under surface of the tongue has no papillae. Note the midline lingual frenulum that connects the tongue to the floor of the mouth. At the base of the tongue, the duct of submandibular glands ( Whartons ducts ) passes forwards and medially to open on papillae that lie on each side of the lingual frenulum. Each parotid duct ( Stensens duct ) empties into the mouth near the upper 2nd molar where its location is marked by a small papilla. The buccal mucosa lines the cheeks. Above and behind the tongue, there is an arch formed by the anterior and posterior pillars , soft palate and uvula . The tonsils lie between anterior and posterior pillars on each side. In the adult, the tonsils are often small or absent. A meshwork of blood vessels may web the soft palate. Between the soft palate and the tongue, the pharynx is visible (Fig. 6.1). Examination The examination of mouth and pharynx is conducted with the patient sitting up comfortably either in bed or in a chair. A torch light, a tongue depressor (spatula) and a pair of gloves are essential. The examination sequence includes; Inspection of the lips, teeth, gums, tongue, palate and oropharynx Palpation of the sides of the tongue, floor of the mouth and tonsillar regions. Inspection The lips The parts of the lips to be examined for their clinical significance are depicted in the Table 6.1. The teeth Ask the patient to show the teeth. If the patient has a denture, ask him/her to remove it and open the mouth T he Mouth and the Phar ynx 6 Fig. 6.

110 Clinical Methods in Medicine THE EAR Anatomy and physiology The ear has three compartments; the external ear (auricle and ear canal), the middle (air filled cavity containing the three bony ossicles) and the internal ear (cochlea, utricle and three semi-circular canals). Functions I . The ears are concerned with hearing Vibrations of sound pass through the air of the external ear and are transmitted through the ear drum and ossicles of the middle ear to the cochlea of inner ear. The cochlea senses and codes these vibrations and sends them up as nerve impulses to the brain through cochlear division of VIIIth cranial nerve. This pathway of hearing has two phases; Conductive phase (from external ear to middle ear) and sensorineuronal phase (cochlea and cochlear nerve). The involvement of conductive phase produces conductive hearing loss while that of sensorineuronal phase produces sensorineural or nerve type of hearing loss. Air conduction describes the normal first phase in the hearing pathway. An alternative pathway, known as bone conduction bypasses the external and the middle ear and is used for testing purposes. In bone conduction a vibrating tunning fork is placed on the head, sets the bone of the skull into vibrations and stimulates the cochlea directly. In normal person, air conduction is better than bone conduction (AC > BC) 1 . To maintain equilibrium The labyrinth within the inner ear senses the position and movements of the head and thus helps to maintain balance. Symptomatology of ear disease The main symptoms of ear diseases are; 1. Aural pain ( otalgia ) 2. Ear discharge ( otorrhoea ) 3. Deafness (hearing loss) 4. Tinnitus (the sensation of sound in the absence of an appropriate auditory stimulus) 5. Vertigo (sensation of abnormal movements) Otalgia The pain in the ear (otalgia) may be due to involvement of pain sensitive structures i.e. external ear canal, tympanic membrane and middle ear. The pain may be referred to ear from other structures i.e. larynx and pharynx which share the sensory innervation. The sensory innervation of ear is 5th, 9th and 10th cranial nerves and branches of greater auricular and lesser occipital nerves. Since division of these cranial nerves also supply larynx, pharynx, temporomandibular joints and teeth, therefore primary involvement of these structures may give rise to referred ear pain. The causes of otalgia are given in the Box 7.1. Box 7.1: C AUSES OF OTALGIA 1. Diseases of the skin and auricular cartilage Infection (furunculosis) Trauma due to cotton buds used to remove the wax from ear canal or by using other articles A squamous-cell or basal cell carcinoma of external ear Perichondritis Subperichondrial haematoma due to external blunt trauma Polychondritis helix (tender nodules on helix) Tophaceous gout (gouty tophi on the helix) 2. Diseases of middle ear Acute suppurative otitis media secondary to upper respiratory or sinus infection in children T he Ear , Nose, Sin uses and T h r o a t 7 Contd....

122 Clinical Methods in Medicine THE NECK The neck should be inspected and palpated. Physical abnormalities in the neck are common. Swellings in the neck are usually palpated best from behind. The structures to be examined in the neck are: 1. The skin. It is to be examined as usual for any lesion 2. The lymph nodes 3. The salivary glands 4. The trachea and the thyroid 5. Neck movements (read Chapter on Nervous system examination) 6 . Carotid and subclavian pulsationsRead peripheral vascular system examination under CVS examination 7. Jugular veins (Read CVS examination). Inspection Inspect the neck, noting its length (Fig. 8.1), symmetry and any mass(es) or swelling(s) Look for enlargement of parotid or submandibular glands, and note any visible swelling or lymph node(s) Note any swelling in the region of the thyroid and any deviation of the trachea. If trachea is markedly deviated to one side, the sternomastoid muscle stands prominent on that side (Trails sign) Note any visible pulsations in the neck Note any deviation of neck to any side (Fig. 8.2). Palpation Palpate the lymph nodes. The important groups of lymph nodes available for palpation are diagramma- tically represented in Fig. 8.3. Sites of lymph nodes in the neck: 1. Preauricular -in front of the ear 2 Posterior auricular superficial to mastoid process behind the ear. T he Nec k 8 Fig. 8.2: Torticollis (Wry neck) due to drug toxicity. Note the tilting of neck to one side due to muscular spasm Fig. 8.1: Abnormalities in the length of neck. A. A child with short neck as a congenital deformity. B.

The Breast and the Axillae 131 THE BREAST AND THE AXILLAE Applied anatomy and physiology The female breast lies against the anterior chest wall extending from the 2nd rib down to the 6th rib, and from the sternum across the midaxillary line. Its surface is rectangular rather than circular. The breast overlies the pectoralis major. The stages in the development of the female breast are diagrammatically illustrated (Fig. 9.1). The commonest site for nipple development is the 4th intercostal space on the midclavicular line, but accessory breast/nipple tissue may develop anywhere down the nipple line ( axilla to groin ). To describe the clinical findings, the breast is often divided into the nipple, the areola and four quadrants based on the horizontal and vertical lines crossing at the nipple (Fig. 9.2). The nipple consists of erectile tissue covered with pigmented skin, which also covers the axilla. The opening of the lactiferous ducts may be seen near the apex of the nipple. Alternatively, instead of quadrants, finding can be localised as the time on the face of a clock (e.g. 6 Oclock) and the distance in centimeters from the nipple. The size and shape of the female breast vary widely and are influenced by hereditary factors, sexual maturity and the phase of menstrual cycle, parity, pregnancy and lactation and the general state of nutrition. The amount of fat and stroma surrounding the glandular tissue largely determines the size of the breast except during lactation (e.g. breast enlargement is glandular). The breast is hormonally sensitive tissue, responsible to the changes of monthly cycling and ageing. In premenopausal women, its consistency may vary considerably in response to fluctuations in oestrogen and progestrone levels during menstrual cycle and in pregnancy. Swelling and tenderness due to fluid retention and prominence of the glandular elements of the breast are more common in premenstrual phase. With advancing age, there is a reduction in the amount of glandular tissue with a corresponding increase in the amount of fat. Therefore, the breasts become softer in consistency and more pendulous. The breasts of lactating mothers are swollen and engorged with milk, hence, are best examined after breast-feeding or milk expression. T he Br east and the Axillae 9 Fig. 9.2: Various quadrants of the breast (diag) Fig. 9.1: Stages of development of female breast (diag). A. Pre- pubertal breast, B. Breast budding (initial stage), C. Enlargement (primary mount), D. Secondary mount formed by areola, E.

The Extremities 139 EXAMINATION OF EXTREMITIES After examination of head and neck, axillae and breasts, now turn to the examination of extremities. The formal physical assessment often begins with examination of hands followed by feet. The hands and the nails Applied anatomy and physiology The hand is a well developed structure and its cortical (cerebral) representation occupies a larger area (Remember, the smaller parts have wider cortical representation). The examination of hands begins with inspection for gross abnormality and then examination of individual structures on an anatomical basis. The keratinous nail plate is produced mainly in the nail matrix which lies in the nail fold on the back of the terminal phalanx of each digit. The matrix runs from the end of the floor of the nailfold to the distant margin of the lunula (half moon) , and from it, the nail plate grows forward covering the nail bed. A small part of the nail and the under surface are formed from the cells in the nail bed. Nail grows throughout life. Finger nails grow faster than foot nails, the growth in the finger nails being approximately 1 cm in 3 months. Steps of examination 1. Inspect the general features of the dorsal and palmar aspects of the both hands . The abnormalities are given in the Box 10.1. Box 10.1: H AND AS A DIAGNOSTIC TOOL Morphological feature Diagnosis Flexed posture of hand Hemiplegia (Fig. 1.33th in Bed and arm side medicine without tears by prof SN Chugh) Large hands and palms Gigantism (see Fig. 3.3), Marfans syndrome (see Fig. 3.4) Short spade-like hands Acromegaly (Fig. 10.1) Wrist drop Radial nerve palsy, lead neuropathy, other peripheral neuropathies Ulnar deviation of hand Rheumatoid arthritis Main Deaccoucheur or Tetany (Fig.10.2) obstetric hand Deformity Trauma, rheumatoid arthritis Claw hand (main-en- Paralysis of interossei and griffe) lumbricals Oedema of hands May be part of generalised oedema, may be due to local venous or lymphatic obstruc- tion or dis use in hemiplegia T he Extr emities 10 Fig. 10.1: Acromegalic hands. Note the short hand with short stubby stout fingers Fig. 10.2: De accoucheurs hand (also called obstetric hand).

III Chapters 1 1 . The Cardiovascular System 153 - 202 1 2 . The R espiratory System 203 - 235 1 3 . The Abdomen 236 - 283 14. The Urogenital System and Sexually T ransmitted Diseases 284 - 314 15. The Nervous System 315 - 402 16. The Examination of Unconscious P atient 403 - 412 17. The Locomotor System 413 - 455 1 8 . The Blood 456 - 473 1 9 . The Psychiatric Assessment 474 - 490 2 0 .

The Respiratory System 203 HISTORY Symptoms Cough and expectoration Haemoptysis Pain chest Dysphagia, hoarseness of voice Present history Past history Measles, whooping cough during childhood, diabetes, T.B., H.T, pneumonia, chest injury, epilepsy, pregnancy and exposure to STD and HIV. Family history Allergy (e.g. hay fever, asthma), T.B. etc. Personal history e.g. record occupation and menstrual history in female GENERAL PHYSICAL EXAMINATION ( G P E ) Built, nutrition, consciousness Facial appearance e.g. puffines, pallor, bluishness, dyspnoea Skin e.g. pallor, purpuric spots The eyes e.g. for jaundice, anaemia, suffusion, periorbital oedema The ear, nose, throat e.g. sinus tenderness, tonsils enlargement or for any septic focus Mouth, pharynx and posterior pharyngeal wall for any septic focus and foul breath Lips and tongue for purselip breathing, cyanosis Neck e.g. lymph nodes, JVP carotid pulsations, thyroid, trachea and activation of extra- respiratory muscles Hands and feet e.g. clubbing, cyanosis, oedema SYSTEMIC EXAMINATION Inspection Deformity (e.g. pectus excavatum), Scars, Intercostal indrawing/recession Symmetry of chest expansion Paradoxical/abnormal movements Movements of extra-respiratory muscles Apex beat e.g. visible or not, displaced or normal Palpation Cervical lymphadenopathy Trachea : Central or displaced Cardiac apical impulse: displaced or normal Chest expansion (measurement) Intercostal spaces (wide, narrow, normal) vocal fremitus (e.g. normal or abnormal) Percussion Percussion note (resonant, dull, stony dull) Define cardiac dullness and liver dullness (increased, normal/ masked/shifted) Auscultation Breath sounds (e.g. normal, bronchial, louder or softer) Added sounds e.g.

236 Clinical Methods in Medicine T he Abdomen 13 FORMAT FOR THE ABDOMINAL EXAMINATION HISTORY Symptoms Upper GI symptoms, e.g. dysphagia, heart burn, vomiting, haematemesis. Lower GI symptoms, e.g. pain abdomen, diarrhoea, abdominal dis- tension, rectal bleeding, weight loss. Hepatobiliary symptoms e.g. jaundice, mass abdomen, ascites, haematemesis etc. Present history Ask about time of onset of symptoms, progression, relation to meals, aggravating and relieving factors, history of prior surgery and medication etc. Past history e.g. DM, HT, past surgery, history of jaundice, haematemesis, drug etc. Family history Personal history Habits, e.g. alcohol, smoking GENERAL PHYSICAL EXAMINATION Face e.g. expression, agony, pallor, pigmentation Eyes e.g. jaundice, pallor Mouth e.g. ulceration, cracks at the angle, fissuring of lips, vesiculation. Teeth and gums for dis- colouration, staining, gum bleeding, erosion Tongue for asymmetry, coating, dehydration, pigmentation, atrophy Neck for JVP, carotid bruit, lymph nodes enlargement. Skin e.g. bleeding spots, telangiectasia, pigmentation Hands and feet e.g. clubbing, koilonychia, platynychia, oedema (pedal, sacral), signs of liver disease (palmar erythema). SYSTEMIC EXAMINATION Inspection Shape, symmetry and movements of abdomen. Umbilicus e.g. position, contour, inflammation, hernia Any abdominal pulsation Hernial sites, groin, scrotum Skin of abdomen for scar, striae, veins, pigmentation, bleeding, rash Palpation Feel for tenderness, rebound tenderness, rigidity or guarding Palpate for any enlarged viscera/ mass. Palpate for abdominal pulsations Elicit the fluid thrill if ascites is suspected. Palpate for divarication of recti Percussion Percussion note of abdomen i.e. normal/abnormal (dull note or hyperresonant note) Percuss over the mass, flanks for dullness. Define upper and lower borders of liver and calculate the liver span Elicit shifting dullness for ascites if suspected.

284 Clinical Methods in Medicine HISTORY Symptoms Polyuria, oliguria, increased frequency, dysuria, nocturia Mass abdomen Hesitancy, precipitancy, inconti- nence, dribbling, swelling of face and abdomen, Sex related complaints e.g. sexually transmitted disease Menstrual complaints, discharge per vagina. Present history, Past history DM, HT, colic arthritis etc. Family history of any heredo familial diseases. GENERAL PHYSICAL EXAMINATION Face - puffiness, pallor Eyes e.g. oedema, xanthelasma Mouth, oral mucosa, tongue Ear for tophi Neck for JVP for fluid overload, carotid pulsations Skin e.g. purpura, bruising, pruritus, uraemic frost Extremities for oedema, clubbing, peripheral neuropathy. T he Ur o g enital System and Sexually T r ansmitted Diseases 14 SYSTEMIC EXAMINATION Abdominal examination I. Inspection for any local bulge II. Palpation for enlarged kidneys, urinary bladder. Local tenderness in renal angle III. Percussion over the palpable kidneys/mass IV. Auscultation for renal or other arterial bruit Genitalia examination Male genitalia Inspect the penis and scrotum for; Infection, ulceration, rash, excoriation, abnormality of prepuce, penis, urethra for any discharge. Inspect scrotum for swelling, oedema, hernia. Palpation of penis and scrotum for discharge, epididymus and spermatic cord (tenderness, sensation), prostate enlargement Female genitalia Inspection of cervical os, uterus, adnexa for any abnormality Palpation for any mass in relation to uterus, cervix, vagina and adnexa, papsmear examination Provisional diagnosis Differential diagnosis Investigations THE URINARY SYSTEM (Fig 14.1) Applied anatomy and physiology Kidneys are 11-14 cm in size, bean-shaped organs, placed in the retroperitoneal paravertebral space in relation to three thoracic vertebrae. Nephron is the fundamental, structural and functional unit of the kidneys. The kidneys are supplied by a pair of renal arteries, each arising from the abdominal aorta. The glomerulus is a bunch of capillaries placed in the Bowmans capsule, the afferent of which receives blood from the systemic circulation and passes it through the glomerulus to the efferent arteriole, which arborises to supply blood to the proximal and distal convoluted tubules and collecting ducts (Fig. 14.2). The medulla is supplied by arterioles arising from the glomeruli in the deeper regions of the cortex.

The Nervous System 315 T he Ner v ous System 15 HISTORY Symptoms (read chap. 2) Symptoms of higher function e.g. change in mood, memory, orientation, consciousness, insight etc. Headache-vertigo, syncope Stroke, epilepsy, cranial nerve palsy Motor e.g. paralysis, weakness, atrophy, involuntary movements Sensory symptoms e.g. abnormal or loss of sensations. GENERAL PHYSICAL EXAMINATION Head and scalp e.g. size, shape and neck stiffness. The skin e.g. naevus, haeman- gioma, sebaceous adenoma, bleeding spots, infection (herpes, HIV). The eyes including fundus Mouth and oral cavity Ear, nose and paranasal sinus Neck for lymph nodes, thyroid disease and carotid bruit. Axillae for lymph nodes Extremities e.g. posture, spasm, cramps, deformities, wrist and foot drop, wasting, abnormal movements, oedema. Fingers and nails Back -scoliosis, winging of scapula, tuft of hair, gibbus or spinal deformity. SYSTEMIC EXAMINATION Higher cerebral functions Appearance, mood and behaviour Emotional status Memory, intelligence Orientation, delusions and hallucinations Consciousness Released reflexes Speech and language Cranial nerves (I to XII). Motor function W asting, fasiculations Abnormal movements Tone, strength (power) Coordination Reflexes (superficial, deep and plantar) Sensory system (Sensations) Pinprick, light touch, temperature Deep touch, position, vibration, stereognosis Tactile localization, two-point discrimination. Autonomic functions Standing test for postural hypotension Handgrip and Valsalva test Other tests Gait and posture Arm swing Tandem (heel-toe) Rombergs test Diagnosis Site of lesion (anatomical) Neurological deficit i.e. tracts involved (physiological lesion) Cause of the disease (Pathological lesion) Differential diagnosis Investigations e.g.

The Examination of Unconscious Patient 403 HISTORY Symptoms Patient is brought in unconscious state Present history Ask for (Figures) Mode of onset of coma Details of neurological symptoms before falling unconscious History of trauma, detail of illicit drug/poison or alcoh ol Past history Ask for liver and kidney disease, HT, diabetes, endocrinal disease, cardiovascular disease or arrhythmias or epilepsy etc. Family history Personal history GENERAL PHYSICAL EXAMINATION First of all assess for vital signs e.g. patent airway, injury to cervical spine, pulse, BP, respiration, convulsions. Start the management if vital parameters are disturbed and perform examination later on Examination of the skull e.g. for trauma Eyes for haemorrhage, ptosis, pupils for size and reaction Face for pallor, asymmetry, injury Mouth e.g. bleeding, tongue bite, smell Ear, nose for bleeding. Skin for bleeding Neck for neck rigidity, lymph nodes. T he Examina tion of Unconscious P a tient 16 FORMAT FOR EXAMINATION OF COMATOSED PATIENT A. AN UNCONSCIOUS PATIENT ON TROLLEY IN ACCIDENT AND EMERGENCY DEPARTMENT, B. EXAMINATION OF UNCONSCIOUS PATIENT INCLUDING BASIC NEUROLOGICAL EXAMINATION SYSTEMIC EXAMINATION Nervous system Level of consciousness, posturing Neck stiffness, cranial nerves Check the size, shape and reaction of pupils to light. Note any conjugate deviation. Look for brain-stem reflexes Dolls eye movements, oculoves- tibular reflex, corneal reflex Look for presence of focal neurological signs or motor paralysis. Elicit the deep tendon jerks for asymmetry. Cardiovascular system Look for cardiomegaly Auscultate for carotid bruit Auscultate the heart for cardiovascular disease or arrhythmia. Respiratory system Note the rate, type and pattern of breathing. Look for chest injury. Auscultate for crackles, rales and wheezes or any respiratory problem or aspiration. Abdominal examination Look for the abdominal distension, rigidity, ascites, hear the intestinal sounds, look for signs of hepatic, renal insufficiency. Endocrinal system Assess for any endocrinal distur- bance especially thyroid.

The Locomotor System 413 HISTORY Important musculoskeletal symptoms Pain Stiffness Weakness Swelling Deformity Non-specific symptoms of systemic illness Present history Ask about; Mode of onset Pattern of joint involvement Number of joints involved Morning stiffness Time relationship e.g. duration, fre- quency of attacks Ask about non-articular manifestations Aggravating and relieving factors Drugs being taken or have been taken Past history e.g. enteritis, sore throat, psoriasis, sexual contact with a women other than wife, intercurrent illness, tuberculosis, gout, surgery. Family history Social and occupational history GENERAL PHYSICAL EXAMINATION (GPE) Appearance e.g. depressed/in agony Face e.g. heliotropic rash, puffiness, pallor etc Eyes e.g. redness, dryness Mouth and buccal mucosa e.g. buccal ulcers, pallor, bleeding Neck e.g. lymphadenopathy, thyroid enlargement, erythema nodosum, haemorrhage Skin e.g. nodules, purpura, petechiae, rash, photosensitivity, Raynauds phenomenon, livedo reticularis Hair e.g. Alopecia, lupus hair Finger and nails e.g. clubbing, nail pitting, splinter haemorrhage, vasculitis, dactylitis, infarct, gangrene Legs and feet e.g. oedema SYSTEMIC EXAMINATION The gals screening for the locomotor system Examination of the joint(s) Inspection Position or posture of limb Note the type of involvement e.g. symmetric or asymmetric Note any swelling, deformity, redness or erythema of overlying skin, muscle wasting, range of active movements of joints. Palpation Palplate for signs of inflammation (active disease) e.g. tenderness. warmth Palplate the swelling if present. Feel for joint crepitus, nodules on the bony prominences. Measurement of passive movement of the joints. Examination of the spine Inspection Look for cervical, thoracic, lumbar curves Look for alignment of shoulders, iliac crests and the skin creases below the buttocks. Look for skin masses, tuft of hair, tag of skin Look for active movement at cervical and dorsolumbar spine Inspection of gait and stance Palpation Perform passive movement and note its range. Perform special tests e.g. straight leg raising, sciatic nerve root stretch tests, femoral nerve stretch tests. Tests for structures around the joint e.g. tendons, carpal tunnel syndrome Examination of the other systems CVS.

456 Clinical Methods in Medicine T he Blood 18 HISTORY Symptoms and signs Anaemia Polycythaemia Bleeding Thrombosis GENERAL PHYSICAL EXAMINATION General observation The face, hair, skin The eyes including ocular fundi The mouth, tongue, the buccal mucosa The neck i.e. thyroid, JVP lymph nodes The axillae for lymph nodes Hands and feet Vital e.g. pulse, temperature, B.P. and respiration S YSTEMIC EXAMINATION Abdomen (Read Chapter 13) Inspection Palpation for liver and spleen or abdominal lymph nodes or any other mass or ascites Percussion Auscultation for bruits, hum or rub CVS Inspection Palpation Percussion Auscultation for abnormal sound and murmurs Respiratory system Auscultation for crackles or wheezes or any other abnormality CNS Higher mental functions Cranial nerves Motor and sensory system Joints (for evidence of bleeding) Diagnosis Differential diagnosis Laboratory investigations Peripheral blood examination Bone marrow Coagulation profile Other specific test s THE BLOOD Blood diseases cover a wide spectrum of illnesses ranging from anaemias, the most common disorders affecting mankind to other relatively uncommon disorders encountered in clinical practice i.e. leukaemias and coagulation defect. Haematological change may occur as a consequence of disease affecting any system and measurement of haematological parameters is an important part of routine clinical assessment.

474 Clinical Methods in Medicine T he Psy c hia tric Assessment 19 HISTORY Symptoms and signs Headache, dizziness Vomiting, functional dyspepsia (nonulcer dyspepsia), irritable bowel syndrome Dyspnoea, hyperventilation Atypical chest pain, palpitations Tinnitus, vertigo Low back pain, myalgia, Chronic fatigue Fibromyalgia Associated with psychiatric symptoms e.g. anxiety, depression, irritability, abnormal behaviour, sleep disturbance etc. History of present illness Past medical history and psychiatric history Family history For example plotting of family tree, socioeconomic status, and history of any psychiatric illness in the family. Personal history PHYSICAL AND PSYCHOLOGICAL EXAMINATION I. Mental status examination General appearance and behaviour Speech Mood and affect Thought Perception and abnormal beliefs Cognition Insight Judgement I I . Cognition (neuropsychiatry) assessment Consciousness Orientation Attention and calculation Registration and recall Language Memory III. Psychological tests Objective tests, e.g. personality and intelligence tests Projective tests Neuropsychological tests Diagnostic psychological tests Rating scales Investigations Medical screen Toxological screen/levels Electrophysiological tests Imaging studies Neuroendocrine studies General observations Appearance, behaviour, dress and clothes, facial expression, grooming, personal hygiene. Drug/substance abuse THE PSYCHIATRIC ASSESSMENT The prevalence of psychiatric illness in our society is so high that every doctor must be able to carry out a psychiatric assessment. Familiarity with the technique of psychiatric assessment is important not only for the psychiatrist but also for a medical specialist or practitioner, since a large percentage (more than one- third) of medical patients have psychiatric disorders. Medically unexplained symptoms and their clinical presentations Some physical symptoms cannot be explained when one does not find a definite physical disease as a cause, one labels them as medically unexplained symptoms. These are commonest and often most frustrating to the primary care physicians.

The Endocrinal System 491 T he Endocrinal System 20 HISTOR Y Symptoms Alteration in height e.g. increase or decrease Weight gain or loss Polyuria and polydipsia Menstrual irregularity Thyroid swelling with or without signs of thyrotoxicosis Hypothyroidism or its features Gynaecomastia Hirsutism Myopathy or muscle weakness Present history Chronological order of symptoms Mode of onset, their progression and course Drugs treatment being taken e.g. replacement therapy or oral contraceptives Past history e.g. details of pregnancies or PPH in females, previous surgery, radiation to neck or gonads and developmental milestones in children Family history e.g. DM or any other endocrinal or autoimmune disease. GENERAL PHYSICAL EXAMINATION Appearance, built, height, weight BMI and body proportions Face e.g. periorbital oedema, moon- facies, prognathism etc. Eyes e.g. exophthalmos, proptosis, signs of Graves ophthalmopathy, visual acuity Ear e.g. deafness Mouth e.g. large protruding tongue, thick lips etc. Neck e.g. goitre, carotid pulsa- tions/bruit, JVP. Breast e.g. Atrophy in female, gynaecomastia and galactorrhoea Skin and hair e.g. dry, wet, hair loss, hirsutism, striae, pigmenta- tion, thin or thick skin, necrobiosis lipoidica diabeticorum Extremities e.g. Long/short, hands (longs/short/extra finger), ulcera- tion, oedema feet, pressure sores or loss of finger s etc. SYSTEMIC EXAMINATION 1. Cardiovascular Look for cardiomegaly Auscultate for change in heart rate, rhythm, murmur or any other abnormal sound 2. Nervous system Look for higher function, cranial nerve, speech Look for abnormal movements Motor system exami- nation for brisk or delayed jerks or myopathy Sensory system exami- nation for neuropathy including carpal tunnel syndrome 3. Genitalia and breast Look genitalia for hyper or hypogonadism Virilisation Breast development, atrophy and galacto- rrhoea 4. Bone and joints Look for osteoporosis, crush fractures or arthropathy 5. Psychiatric assess- ment for depression or anxiety or abnormal behaviour.

Appendices Sample Collection Correct sample collection and correct type of container are essential for laboratory investigations. Specimens taken/obtained are taken to the laboratory by the ward boy as soon as they are obtained. If they are to be sent by post, then they should be suitably packed and labelled Handle with care and pathological specimens . Such samples /specimen are first sealed in the inner container and placed in a secure carton containing sufficient absorbent material so as to dry up all the liquid contents spilled if the inner container is broken. Local and International regulations for the transmission of pathological material must be adhered to strictly. Suitable container are usually provided by the laboratory that is going to analyse the sample/specimen. All the container must be clean and sterile for microbial examinations; while the container for blood sample must be perfectly dry. They should have properly fitting cap or lid. I t is essential to use correct container for each investigations, for example, anticoagulant may be necessary for certain investigations while coagulated blood may be needed for others. It is also essential that suitable amount of the blood should be put into the container. It is also mandatory that the nurse/doctor taking the blood sample must use the sterilised/disposable type of syringe and needle. Venepuncture (Fig. A.1) This is to make a puncture in the vein to collect the sample. The site selected is the vein in the antecubital fossa or any other prominent superficial vein. The steps of venepuncture are: 1. Make the vein prominent by a tourniquet (use a piece of rubber tubing, duputta, a sling or by manual sequeezing of arm, etc) applied over the middle of the arm. 2 . Clean the area to be punctured by alcohol/spirit/ savlon or any other antiseptic solution. 3 . Stretch the skin at the elbow with your left hand. 4. The patient is asked to make fist. Introduce the needle in the vein and move it upwards further in the direction of the vein. 5 . The blood will enter automatically into the syringe. The venous blood is dark in colour. Take the required amount of the blood in the syringe. Remove the tourniquet, before the needle is withdrawn. 6. Alternatively, you can remove the tourniquet as soon as the needle enters the vein so that free flowing blood is withdrawn as in shocked patients. 7. As soon as the needle is withdrawn, a swab is placed on the punctured site and the patient is asked to bend the elbow so that forearm presses over the swab against the arm for one minute or so.