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Medical Case History Taking & Examination In Medicine : Procedure, Steps, & Format

Medical Case History Taking & Examination Medicine : Procedure, Steps, & Format

(A). History Taking

History is the record of medical events or conditions that have already taken place in the patient. Because every disease have a specific pattern of behaviour, a well considered history combine with knowledge of medicine would help the doctor to judge the likely cause(s) which may be responsible for patient’s problem.

A practitioner typically asks questions to obtain the following information in a systemic order about the patient for a good history:

1. Biodata of patient

  • Name
  • Age
  • Sex
  • Address
  • Occupation
  • Religion
  • Date of admission
  • Right or left handed (CNS) etc.

2. Chief complaint (CC)

The main complaints (one symptom or more complaints) which push the patient to seek the help of doctor.

e.g. chest pain, shortness of breath

  • Symptoms should be recorded in chronological order.
  • It should be recorded in patients own words. Avoid medical terminology.
  • It should be short & specific in clear sentence.

3. History of the Present Illness (HOPI) or History of presenting complaint (HPC)

Details about the complaints, enumerated in the chief complaint (CC) i.e. elaborate the chief complaints or symptoms separately in detail.

e.g.

  • Onset – Sudden/Gradual
  • Duration
  • Present status of symptom
  • Progression

There should be sequential presentation. It should be narrated in detail.

  • e.g. 2 week before the admission, patient fell while working in field & cut his hand with a stone. By that evening, the hand became swollen & patient was unable to walk. Next day patient attended JLN hospital & they give him some oral antibiotics besides doing dressing. He doesn’t know the name of antibiotics. There is no improvement in his condition and 3 days before the admission, the hand continued to swell & started discharging pus. There is high fever.

If patient has more than one symptom, each symptom should be recorded separately in detail.

Describe each symptom in chronological order i.e. symptom which occurred first should be mentioned first and which appeared later should be mentioned after this.

It should be recorded in patients own words. Avoid medical terminology.

Associated symptoms

  • Associated symptoms must also be inquired into & recorded.

4. Negative History

  • Associated negative history relevant to suggestive system

5. Past Medical History (PMH) or History of Past illness

Similar illness in the past with their details (e.g. time of occurrence, duration, & results) should be noted.

Including

  • Any history of similar complaints in the past.
  • Any previous surgery/operations e.g. time, place, what type of operation.
  • Any other major illnesses or any current ongoing illness e.g. IHD, Heart attack, Asthma, HT, RHD, TB, Jaundice, diabetes. if diabetic, mention time of diagnosis, current medication, clinic check up.
  • History of trauma, accidents, hospital stay, or blood tranfusion.
  • Childhood illness (pertussis etc.)

If answer is yes to any of above, give details.

6. Personal History

Including

  • Patient’s appetite
  • Food habits
  • Type of diet (e.g. mixed, veg)
  • Bowel & micturition habits
  • Sleep
  • Addictions like alcohol, smoking, tobacco chewing, charas, ganja etc. (If any, give details like duration, quantity, brand, frequency)

7. Family History

Any familial disease running in families especially those relevant to the patient’s chief complaint e.g. IHD, DM, HTN, Asthma must be recorded.

The state of health of parents, peers & children should be noted. If any member is deceased, the cause of death should be noted.

e.g.

  • Married/Single
  • If married: duration, no. of issues, no. of alive, abortions, pedigree chart
  • If single: no. of brothers/sisters, their health, health of parents
  • H/o familial disease
  • H/o of similar complaints, HT, DM, infections etc.

8. Drug History (DH)

Always use generic name with dosage, timing & how long. i.e. now and past, prescribed and over-the-counter, allergies.

9. Menstrual & Obstetric History (If female)

Including

  • Date of onset of menstruation
  • Date of last menstruation
  • Amount of blood loss
  • Menstruation regularity
  • Pain during menstruation

In a women who has conceived, details of past abortions, premature births and normal or abnormal deliveries should be noted.

10. Sexual History (If required)

  • Pre or extra marital sexual contact
  • H/o multiple partners
  • H/o visiting commercial sex workers
  • Whether homo/hetero/bisexual
  • H/o penile ulcer
  • H/o inguinal swelling, urethral discharge etc.

(B). General Physical Examination

The general examination of patient should be done systematically (head to toe), noting the following:

  • Built
  • Nutrition
  • Counsciousness
  • Co-operative or not?
  • Orientation to time, place, & person
  • Body proportions
  • Height
  • Weight
  • Body mass index (BMI)
  • Body surface area
  • Scalp, hair
  • Eyes (e.g. palpebral conjunctiva, upper part of sclera, sclera on either side of cornea, cornea, pupils, any other)
  • Nose
  • Ears (External pinna, external auditory canal)
  • Neck (Thyroid, lymph nodes, jugular venous pulse & pressure)
  • Upper limbs: Nails (clubbing, pallor, cyanosis), Edema, Skin (pigmentations etc.), Lymphadenopathy (axillary lymph nodes)
  • Sternal tenderness
  • Chest & abdomen
  • Lower limbs: Nails, Edema, Skin, Lymphadenopathy (popliteal & inguinal lymph nodes)
  • Joints
  • Vital signs: Pulse → Blood pressure → Respiration → Temperature (Mnemonic: PBRT)
  • Any other suggestive sign

Pulse

  • Rate
  • Rhythm
  • Volume
  • Character of vessel wall
  • Radio-radial delay
  • Radio-femoral delay
  • Peripheral pulsations
  • Any special character of pulse

Blood pressure

  • Upper or lower limb
  • Supine or standing

Respiration

  • Rate
  • Type
  • Rhythm

Lymphadenopathy

  • Group
  • Number
  • Size
  • Consistency
  • Tenderness
  • Fixity (To each other & surrounding structures)
  • Catchment area

Joints

  • Swelling, erythema, deformity, tenderness
  • Grade (Grade 1: Patient says joint is tender, Grade 2: Winces on touch, Grade 3: Withdrawal of limb, Grade 4: Patient does not allow to touch)

(C). Systemic Examination

Examine the system as suggested after above procedure.

(a). Respiratory System

Upper respiratory tract

  • Nose, nasal cavity
  • Sinus (Frontal, ethmoidal, maxillary)
  • Oropharynx

Lower respiratory tract

All the findings in the clinical examination should be compared on both sides in the following areas:

Anteriorly

  • Supraclavicular area
  • Infraclavicular area
  • Mammary region

Laterally

  • Axillary region
  • Infra-axillary region

Posteriorly

  • Suprascapular region
  • Interscapular region
  • Infrascapular region

A. Inspection

Chest

  • Shape
  • Symmetry (Look for lie of ribs, shoulder drooping, intercostal space, spine, flattening, hollowing, fullness, suprascapular fossa, spinoscapular distance)
  • Movement: Rate, rhythm, equality and type of breathing

Position of mediastinum

  • Trachea: Trail’s sign (Present or Absent)
  • Apex beat: It is shifted to the side of mediastinal shift

B. Palpation

Confirmation for position of mediastinum

  • Trachea: Confirmation of trail’s sign (Present or Absent). Slight shift of trachea to the right is normal.
  • Confirmation of apex beat

Confirmation for respiratory movements

  • Assessment of anterior thoracic movement
  • Assessment of posterior thoracic movement

Assessing Symmetry of Chest Expansion

  • Assessment of upper thoracic expansion

Measurement of the Chest Expansion

  • Chest circumference (cm)
  • During deep inspiration

Tenderness

  • Intercostal spaces
  • Ribs

Tactile vocal fremitus

C. Percussion

The sitting posture is the best position of choice for percussion. Supine posture is not desirable because of the alteration of the percussion note by the underlying structure on which the patient liesa.

Percussion should be done both side (comparing each other) in following posture:

  • Anterior percussion: The patient sits erect with the hands by his side
  • Posterior percussion: The patient bends his head forwards and keeps his hands over the opposite shoulders. This position keeps the two scapulae further away so that more lung is available for percussion.
  • Lateral percussion: The patient sits with his hands held over the head.

Anterior Chest Wall

  • Clavicular
  • Supraclavicular (Kronig’s isthumus)
  • Infraclavicular
  • 2nd to 6th intercostal spaces

Lateral Chest Wall

  • Fourth to seventh intercostal spaces

Posterior Chest Wall

  • Suprascapular (above the spine of the scapula)
  • Interscapular region
  • Infrascapular region up to the 11th rib

Right Side

  • Liver dullness (Upper border)
  • Tidal Percussion

Left Side

  • Traube’s Space
  • Cardiac dullness

D. Auscultation

Auscultatory areas are as following

  • Anteriorly: From an area above the clavicle down to the 6th rib
  • Axilla: Area upto the 8th rib
  • Posteriorly: Above the level of the spine of the scapula down to the 11th rib

What to observe?

Air entry

Type of breath sounds 

  • Vesicular
  • Bronchial
  • Vesicular with prolonged espiration

Absent Breath Sounds

Added Sounds

  • Crepts
  • Rhonchi

Pleural rub

Pleuro-pericardial rub

Voice Sounds

  • Vocal resonance (Bronchophony, Aegophony, Whispering pectoriloquy)

Other foreign sounds

  • Stridor

Special Tests (If required)

  • Heimlich’s manoeuvre
  • Post-tussive suction
  • Succussion splash
  • Coin test
  • DeEspine’s sign

(b). Gastrointestinal Tract

A. Inspection

Shape of abdomen

Umbilicus

  • Normal
  • Everted
  • Omphalolith
  • Slit

Movements with respiration (Quadrants of abdomen)

Visible peristalsis

Skin or Surface of Abdomen

  • Dilated or engorged veins (Part of abdomen, Direction of flow)
  • Caput medusae
  • Purple striae
  • Striae atrophica or gravidarum

Hernial orifices

Divarication of recti

Measurements

  • Abdominal girth
  • Distance between lower end of xiphisternum to umbilicus and from umbilicus to symphysis pubis

Scrotum

B. Palpation

Superficial

  • Tenderness
  • Rigidity

Deep

Start in left iliac fossa palpating lightly and working anti-clockwise to end in suprapubic region. The order of palpation of organs are:

  • Left kidney
  • Spleen
  • Right kidney
  • Liver
  • Urinary bladder
  • Aorta and para-aortic glands and common iliac vessels
  • Palpate both groins
  • Examine external genitalia

Describe about size, surface, margins, consistency, tenderness.

C. Percussion

Organ percussion

  • Liver
  • Spleen
  • Any other lump

Percussion for free fluid in abdomen

  • Fluid thrill (This is felt when there is a large amount of fluid under tension, i.e. > 2000 ml)
  • Shifting dullness (About 1000 ml of fluid should be present to elicit this sign)
  • Horse-shoe shaped dullness
  • Puddle sign (It can detect as little as 120 ml of ascitic fluid)

Percussion of Cyst

  • Hydatid Thrill

D. Auscultation

What to observe?

Bowel sounds (peristaltic sounds)

Arterial bruit

Paraxiphoid venous hum

Friction rub (Hepatic/Splenic)

Succussion splash

(c). Central Nervous System

A. Higher Mental Function Examination

Consciousness

  • Level of consciousness (whether the patient is comatose, stupor or delirious) : Glasgow Coma Scale (GCS)

Orientation to time, place, & person

Memory

Intelligence

Handedness

Perceptions

  • Delusions
  • Hallucinations
  • Illusions
  • Obsessions

Apraxia

Agnosia

Sleep

Speech and Language

  • Spontaneous speech
  • Naming objects, concepts
  • Comprehension of spoken commands
  • Reading aloud
  • Handwriting

B. Cranial Nerve Examination

1st Cranial Nerve (Olfactory Nerve)

  • Sense of smell

2nd Cranial Nerve (Optic Nerve)

  • Visual acuity : Finger counting at 1 meter
  • Visual fields : Confrontation method
  • Colour vision
  • Pupillary responses

3rd, 4th, 6th Cranial Nerves (Oculomotor, Trochlear, Abducent respectively)

  • Inspection (Diplopia, squint, nystagmus, ptosis, pupil-size, symmetry)
  • Examination proper (eye ball movements)

5th Cranial Nerve (Trigeminal Nerve)

  • Motor : Masseter and Temporalis Muscles
  • Sensory : Pain, temperature, light touch on face except at angle of mandible; Corneal reflex; Conunctival reflex

7th Cranial Nerve (Facial Nerve)

  • Motor : Ask to – form forehead wrinkles, close eye, raise the eyebrows, show the teeth, blow out the cheeks against the closed mouth, whistle.
  • Sensory : Taste at anterior 2/3 of tongue
  • Secretory : Lacrimation

8th Cranial Nerve (Vestibulocochlear Nerve)

9th & 10th Cranial Nerves (Glossopharyngeal and Vagus Nerves)

  • Gag reflex (Touch cotton at posterior 2/3 of tongue & see contraction of post pharyngeal wall)

11th Cranial Nerve (Accessory Nerve)

  • Sternocleidomastoid : Turn the head against resistance
  • Trapezius : Shrug the shoulders against resistance

12th Cranial Nerve (Hypoglossal Nerve)

  • Protrusion of tongue → Deviation → Same side lesion
  • Appearance of tongue (any wasting, tremor or fibrillation)
  • Power of tongue muscles
  • Tone of tongue

C. Motor System Examination

Nutrition

  • Muscular mass (Muscle girth) : Small muscles of hand, Forearm (above styloid process), Upper arm (above medial medial epicondyle), Leg (above medial malleolus), Thigh (above adductor muscles)
  • Circumference of the limbs : Upper limbs (10 cm above the olecranon, 10 cm below the olecranon); Lower limbs (18 cm above the superior border of the patella, 10 cm below the tibial tuberosity)

Tone

  • Hypotonia
  • Hypertonia (Spasticity, Rigidity)

Check at wrist, elbow, knee, ankle.

Power 

  • Upper limbs
  • Lower limbs

Grading

  • Grade 0 No movement
  • Grade 1 Flicker of contraction
  • Grade 2 Movement with gravity eliminated
  • Grade 3 Movement against gravity
  • Grade 4 Movement against resistance
  • Grade 5 Normal power (As the examiner)

Coordination

  • Upper limb: Finger nose test, Finger-finger-nose test, Dysdiadochokinesis
  • Lower limb: Heel-knee test, Tandem walking

Involuntary (abnormal) movements

  • Tremors
  • Chorea
  • Athetosis
  • Hemiballismus
  • Dystonias
  • Myoclonus
  • Tics
  • Fasciculation
  • Fibrillation
  • Myokymia
  • Minipolymyoclonus
  • Titubation

Gait

Reflexes

  • Superficial : Plantar, abdominal, corneal, conjunctival
  • Deep : Biceps, triceps, supinator (brachioradialis), knee jerk, ankle, patellar clonus, ankle clonus, jaw jerk

D. Sensory System Examination

Touch

  • Crude touch
  • Pressure

Pain

  • Superficial
  • Deep

Temperature

  • Hot
  • Cold

Posterior column sensations

  • Vibration sense
  • Joint sense
  • Muscle sense
  • Fine touch (discriminative)
  • Position Sense (Romberg’s Test)

Cortical sensations

  • Point localisation (Tactile localisation)
  • Two-point discrimination
  • Stereognosis
  • Graphaesthesia

Cerebellar signs

  • Dyssynergia
  • Dysmetria
  • Dysdiadochokinesia
  • Rebound phenomenon
  • Hypotonia
  • Gait
  • Speech disturbances
  • Nystagmus
  • Pendular knee jerk
  • Intention tremor
  • Titubation etc.

E. Sign of meningeal irritation

  • Neck rigidity
  • Kernig’s sign
  • Brudzinski’s sign

(d). Cardiovascular System

A. Inspection

Precordial bulge

Visible pulsations

Apical impulse

  • Location

Shape of chest

B. Palpation

The fingertips are used to feel pulsations, the base of fingers for thrills and hand base for heaves. Ideal position is supine or upper trunk elevated to 30°.

Apical impulse

  • Location
  • Character

Left parasternal heave

Thrills

  • Carotid thrill (Carotid shudder)
  • Aortic thrills
  • Pulmonary thrills
  • Apical thrills

Shocks

  • Aortic area
  • Pulmonary area
  • Apical area

Pulsations

  • Epigastric
  • Supraclavicular etc.

Tracheal tug

C. Percussion

To be done at

Left border

Right border

Left 2nd intercostal space

Right 2nd intercostal space

Upper part of sternum

Lower part of sternum

D. Auscultation

Auscultatory areas are as following:

  • Mitral area corresponds to cardiac apex.
  • Tricuspid area corresponds to the lower left parasternal area.
  • Aortic area corresponds to the 2nd right intercostal space close to the sternum.
  • Pulmonary area corresponds to the 2nd left intercostal space close to the sternum.
  • Erb’s area (second aortic area) corresponds to 3rd left intercostal space close to the sternum.
  • Gibson’s area corresponds to left first intercostal space close to sternum. PDA murmur is best heard here (Gibson’s murmur).
  • Carotids
  • Inter and infrascapular areas
  • Axilla
  • Supra- and infraclavicular areas

Auscultation should proceed in the following manner

  • Mitral area > Tricuspid area > Neoaortic area > Pulmonary area > Aortic area

The heart is auscultated for

Heart sounds

  • 1st heart sound
  • 2nd heart sound
  • Splitting of heart sounds

Note: 

  • Never comment on the 2nd heart sound in the mitral & tricuspid areas.
  • Never comment on the 1st heart sound in the pulmonary & aortic areas.

Heart Murmurs

  • Site where best heard
  • Systolic or Diastolic
  • Timing
  • Character
  • Grade
  • Pitch (Low or high pitched)
  • Posture in which best heard
  • Conduction
  • Relation of phase of respiration (Variation of the murmur with respiration)
  • Whether the murmur is best heard with the bell or the diaphragm of the stethoscope
  • Variation of the murmur with dynamic auscultation (manoeuvres, postures, pharmacological agents like amyl nitrite)

Added sounds

  • S3 heart sound
  • S4 heart sound
  • Opening Snap (OS)
  • Pericardial rub
  • Diastolic knock
  • Tumour plop
  • Prosthetic valve sounds

(D). Provisional Diagnosis

  • Anatomical
  • Pathological
  • Radiological
  • Complications (If applicable)
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