The scheme of case history. Inquiry of a patient.

The scheme of case history. Inquiry of a patient.

General inspection of a patient. Clinical value of obtained data.

Inspection of  separate parts of a body. Clinical value of obtained data.

 

Sequence of interviewing.

The Case History consist of such components as: the identifying data, the main complaints, the history of present illness, the past medical history, the review of systems. The outlined compounds of a case history, being used in the correct order, help to obtain the organized set of data about patient’s condition and disease.

 

Identifying Data and their diagnostic value

Identifying Data include at least age, sex, race, place of birth, present address, marital status, occupation (profession).

 

Patient¢s complaints and their detalization

You should collect main patient’s complaints, when possible, in patient’s own words, and then describe their characteristics. The principal symptoms should be described in terms of their location, quality, quantity or severity, timing (i.e., onset, duration, and frequency), setting, factors that have aggravated or relived these symptoms, and associated manifestations. Then find out and analyze the general complaints. For example, weakness, high body temperature, etc. 

The chief complaint represents the specific reason for the child’s visit to the clinic, office, or hospital. The chief complaint may be viewed as the theme, with the present illness as the setting of this problem. Six guidelines determine appropriate recording of the chief complaint: (1) it consists of a brief statement, (2) it is restricted to one or two symptoms, (3) it refers to a concrete complaint, (4) it is recorded in the child’s or parent’s own words, (5) it avoids the use of diagnostic terms or translations, and (6) it states the duration of the symptoms.

The doctor elicits the chief complaint by asking open-ended neutral questions such as, “Tell me what seems to be the matter?”, “How may I help you?” or “What brings you here?”  Labelling-type questions such as, “How are you sick?”, should be avoided, since is possible that the reason for the visit is not because of illness. For example, the visit may be for a routine health assessment, or the chief complaint may be of a nonphysical nature.

Examples of properly recorded chief complaints for a variety of situations may be: (1) ambulatory clinic – “My child has had a runny nose and sore throat for 4 days, but today it is worse”, (2) hospital admission – “I need to have my tonsils fixed”, sore throat and repeated earaches for 5 years, and (3) health centre – “We are here for a routine checkups”, last visit 1 year ago.

If the visit is for examination, one can ask, “Before we begin, is there anything of particular concern that you would like to discuss?”. This type of statement encourages the parent (or child) to bring up an issue that may not surface during routine interviewing.

Occasionally it is difficult to isolate one symptom or problem as the chief complaint because the parent may identify many. In this situation it is important to be as specific as possible when asking questions. For example, asking informants to state which one problem or symptom caused them to seek help now may help them to focus on the most immediate concern.

 

 

  Patient’s present illness history

The history of present illness is a clear,  chronological narrative  account  of the problems which the patient is seeking care for. It should include the onset of the problem, the setting in which they was developed, their manifestations,  treatment, their impact upon the patient’s life, and meaning to the patient. Relevant data from the patient’s chart, such as laboratory reports, also belong in the present illness.

The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Its four major components are (1) details of onset, (2) complete interval history, (3) present status, and (4) reason for seeking help now. The focus of the present illness is on all those factors that are relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present.

Analyzing of symptoms. Since pain is often the most characteristic symptom denoting onset of a physical problem, it is used as a prototype for analysis of a symptom. The doctor should assess pain for (1) type, (2) location, (3) severity, (4) duration, and (5) influencing factors. The type or character of pain should be as specific as possible.

By type pain may be acute, throbbing, dull, aching, stabbing, and so on. Whatever words they use should be recorded in quotes.

The location of the pain also must be specific. “Stomach pains” is too general description. Sometimes it is necessary to ask to “point with one finger to where it hurts”. The doctor can also determine if the pain radiates by asking, “Does the pain stay there or move? Show me where it goes with your finger“.

The severity of pain is best determined by finding out how it affects the patient’s usual behaviour. It is preferable to record pain in terms of interference with activity.

Duration of pain should include the duration, onset, and frequency of attacks. Influencing factors are anything that causes a change in the type, location, severity, or duration of the pain. These include (1) precipitating factors (those that cause or increase the pain), (2) relieving factors (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down, and so on), and (5) associated events (meals, stress, coughing, and so on).

A standard method of analyzing a symptom is listed in the following outline. These three categories - onset, characteristics, and course since onset - comprise the essential data for the present illness. Although the analysis of a symptom has concentrated on discussion of physical complaints, the same process of description and investigation can be used for emotional or psychosocial problems.

 

Analysis of a symptom

                   I.      Onset

a)          Date of onset,

b)         Manner of onset (gradual or sudden),

c)          Precipitating and predisposing factors related to onset (emotional disturbance, physical exertion, fatigue, bodily function, pregnancy, environment, injury, infection, toxins and allergens, therapeutic agents, and so on).

               II.       Characteristics

a)            Character (quality, quantity, consistency, or others),

b)           Location and radiation (of pain),

c)            Intensity or severity,

d)           Timing (continuous or intermittent, duration of each, temporal relationship to other events),

e)            Aggravating and relieving factors,

f)             Associated symptoms.

III. Course since onset

a)           Incidence

·          Single acute attack.

·          Recurrent acute attacks.

·          Daily occurrences.

·          Periodic occurrences.

·          Continuous chronic episode.

b)           Progress (better, worse, unchanged),

c)           Effect of therapy.

 

Past history:

The general state of health:

Previous diseases including viral hepatitis, sexual-transmitted diseases, infectious diseases within the last month, AIDS-risk factors

2. Immunizations: tetanus, diphtheria, polio etc.

3. Adult illness, operations, injuries, allergies.

4. Current medications, including home remedies, nonprescription drugs, and medicines borrowed from family or friends. When patient seems likely to be taking one or more medications, survey one 24-hour period in detail.

5. Diet.

6. Sleep Patterns. Including times that the person goes to bed and awakens, difficulties in failing asleep or staying asleep, and daytime naps.

7. Habits, including exercise and the usage of coffee, alcohol, other drugs, and tobacco.

8. The Family History:

The age and health, or age and cause of death of each immediate family member (i.e., parents, siblings, and children). Data on grandparents or grandchildren may also be useful.

The occurrence in the family of any of the following conditions: diabetes, tuberculosis, heart disease, high blood pressure, kidney disease, cancer, arthritis, anemia, headaches, mental illness, or symptoms like those of the patient.

Social History: assessment of the home and job environment, professional hazards.

Review of Systems: the relevant items are limited, but expand as the patient’s age increases.

 Systems reviewing:

Carrying out the reviewing of systems you should pay attention to the following:

1. General state of health: weight, recent weight change, weakness, fatigue, fever.

2. Skin: Rashes, lumps, itching, dryness, color changes, changes in hair or nails.

3. Head: Headache, head injury.

4. Eyes: Vision, glasses or contact lenses, last eye examination, pain, redness, excessive tearing, double vision, glaucoma, cataracts.

5. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge.

6. Nose and sinuses. Frequent colds, nasal stuffiness,   hay fever, noseblends, sinus trouble.

7.  Mouth and throat. Condition of teeth, last  dental  examination, sore tongue, frequent sore throats.

8. Neck: Lumps in neck swollen glands, pain in the neck.

9. Breasts: Lumps, pain, nipple discharge, self-examination

10. Respiratory system: Cough, sputum (color, quantity), hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, tuberculin test; last chest x-ray film.

11. Cardiovascular system: high blood pressure, rheumatic fever, heart murmurs; dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema; chest pain, palpitations; past electrocardiogram or other heart tests

         12. Gastrointestinal system: Appetite, nausea, vomiting, vomiting of blood, indigestion, frequency of bowel movements, change in bowel habits, rectal bleeding or black tarry stools, constipation, diarrhea; abdominal pain, food intolerance, meteorism, hemorrhoids; jaundice, liver or gallbladder trouble, hepatitis.

13. Urinary: Frequency of urination, polyuria, nocturia, dysuria, hematuria, urgency, hesitancy, incontinence; urinary infections, stones.

14. Genito-reproductive:

Male: Discharges, history of venereal disease and its treatment, hernias, testicular pain; sexual difficulties.

Female: Age at menarche; regularity, frequency, and duration of periods; amount of bleeding, bleeding between periods or after intercourse, last menstrual period; dysmenorrhea; age of menopause, menopausal symptoms, post-menopausal bleeding. Discharge, venereal disease and its treatment; Number of pregnancies, number of abortions (spontaneous and induced); complications of pregnancy; sexual difficulties.

15. Musculoskeletal system: Joint pains or stiffness, arthritis, backache. Muscle pain.

16. Peripheral vessels: Intermittent claudicating, cramps, varicose veins, thrombophlebitis.

17. Nervous system: Fainting, blackouts, paralysis, local weakness, tremors, memory.

18. Endocrine system: Thyroid trouble, heat or cold intolerance, excessive sweating, diabetes, excessive thirst, hunger, urination.

19. Hematologic: Anemia, easy bruising or bleeding, past transfusions and possible reactions and antibiotics.

 

 

A Scheme of Inquiry

Questioning a patient (Interrogatio)

 General information about a patient (Praefatio)

Name, surname

Sex

Age

Permanent address

Occupation

Place of employment

The name of referral institution

Date of admission to the hospital

Date of discharge from the hospital

 

Patient’s complaints (Molestia aeqroti, Querellae aeqroti)

The main complaints are the main patient’s problems which he is suffered for. Every complaint should be defined with determination of its location, quality, quantity, severity, timing (onset, duration, frequency), the setting in which they occur, factors that have aggravated or relieved them, associated manifestations, any changes of these characteristics in dynamics, appearance of new symptoms.

Full description of complaints should be noted once for do not appaering need of searching different detalis in other parts of the Case History. A curator describes complaints of every system and details them concerning  main suffering system(s).

Then a curator describes in detalis the secondary complaints. To define them is possible only when a doctor asks patients additional questions because these complaints are not so severe.

 

Review of systems (Status presents subjective)

Cardio-vascular system

Does the patient feel pain in the heart region? If yes, you should define the following characteristics:

           -location (behind the sternum, above the apex, over the whole heart area);

           -when does it develop (on physical exertion, emotional overstrain, at rest);

                   -its irradiation (to the left arm, neck, left part of the neck, low jaw, intercapular space, left shoulder-blade);

           -characteristics of pain (acute, dull, constricting, stabbing, burning, pressing, boring, arching, or a sense of heaviness);

-intensity (slight, of moderate intensity, strong, severe);

           -timing (persistent, periodical), if periodical - the frequency of its appearance a day;

           -duration (during some minutes, hours, days);  

           -associated manifestations ;

           -provoking factors (physical or emotional overstrain);

           -factors that relieve or remove the pain;

-patient’s behavior during pain attack, body position that relieves pain.

 

Palpitation. If yes, what are its:

           -frequency (constant, paroxismal);

           -if periodical – duration of an attack, in what time and under what conditions does the attack develop: at physical overload, emotional overstrain, at rest, due to change in posture, without any  reason;

-when does it disappear?

           Is it followed by heart intermissions (a sense of  heart arrest,  heart disposition)? If yes- what is the reason of these unpleasant feelings on the patient’s own opinion?

     Frequency of attacks a day, it duration, factors that relieve or remove the symptom.

 

Feeling of pulsations in different parts of patient’s body: its

-location, frequency, duration;

-relation to palpitation, heart intermissions, pain;

-provoking factors;

-factors that relieve or remove symptom.

 

Does the patient complain of dyspnea? If yes, what is

           -the setting of its development (on exertion, during conversation, emotional overstrain, at rest)?

           -Its type (expiratory,  inspiratory or mixed);

           -is it attack-like or constant?

           -Is it more intensive in recumbent or upright position of the patient?

-Relation of dyspnea to body position (upright, recumbent), physical loading.

   

Suffocation: if present, define its

           -time of appearance (in day-time, at night);

           -frequency of attacks;

           -duration;

           -factors, that relieve the symptom;

           -what time and under what conditions does it develop (on exertion, emotional exertion, at night)?

 

Cough: time and condition of its appearance (in the morning, in the evening, at night);

           -timing (is it permanent or periodical), in the last case - duration and frequency of attacks;

           -loudness and intensity of cough (inssiculation, slight, of moderate intensity, loud);

           -character of cough (dry or with expectoration of sputum (moist);

           -under the what conditions does cough develop or become more severe, its relations to respiration, physical loading, singing, conversation etc.);

-factors that relieve or remove cough.

 

If cough is moist, define amount of sputum discharged per day and in one split;

           -peculiarities of discharging (is it heavy or easy, at what day time and in what body position sputum may be best discharged);

           -colour of sputum (greish, reddish);

           -smell of sputum;

           -are there any admixtures of blood in sputum, if yes, what is the degree of bleeding (blood streaks in sputum, sputum mixed with blood, pure blood in several splits, pronounced bleeding). Colour of  sputum should be clarified (light-red, dark), frequency of bleedings, duration, provoking factors, under the what conditions does bleeding become less intense  or disappear.

 

Edema: if present, what is its location?

           -time of appearance (in the morning, in the evening, all time);

           -under the conditiond does in develop or become more pronounced (physical loading etc.)?

           -Factors, that relieve the symptom (due to usage of diuretics or on its own).

           -Relation of edema to water and salt intake.

Claudicate intermittent: the time of appearance, relieving factors.

The signs of spasm of peripheral arteries: pain in the limbs, feeling of “freezing”, “numbness” of fingers, feeling of “dead” finger, headache, flickering before eyes.

 

Respiratory system

Does the patient breathe through the nostrils freely  or have any  difficulty in breathing ?

Dryness in the throat or behind the sternum (indicate, if present).

Does he (she) feel pain  in the chest, if yes, desribe, please, its location (with indication of topographic zones and lines);

-irradiation (toward which zone);

           -characteristic (acute, dull, stabbing, arching, pressing, boring, stretching, gnawing);

           -intensity (slight, of moderate intensity, strong, severe);

           -timing (constant, paroxismal)? In the last case – time of appearance;

           -provoking factors, especially the relation of pain to breathing movements, coughing, changes of body position;

           -factors that relieve or remove pain.

 

If patient complains of cough, you should determine its

           -time and condition of appearance (in the morning, in the evening, at night);

           -timing (is it persistent or fitlike), in the last case - duration and frequency of attacks;

           -loudness and tembre of cough (weak, of moderate loudness, loud, barking, loudless);

           -hacking cough (inssiculation);

           -character of cough (dry or with expectoration of sputum (moist).

 

If cough is moist, define: volume of sputum discharged per day and in one split;

           -peculiarities of discharging (is it heavy or easy, at what day time and in what body position is sputum discharged);

           -colour of sputum (greyish, yellowish, greenish, reddish);

           -does it smell of putridity?

           -Are there any admixtures of blood in sputum, if yes, what is the degree of bleeding (blood streaks in sputum, sputum mixed with blood, pure blood in several splits, pronounced bleeding);

           -colour of blood in sputum (light-red, dark, with raspberry hue, rusty).

 

Dyspnea: if present, define following:

           -setting of its appearance (at rest or on exertion, degree of loading which conducts dyspnea);

           -is it permanent or periodical, in the last case – duration of attacks;

           -type of dyspnea (expiratory,  inspiratory or mixed);

           -provoking factors (smells, emotional strain, overcooling, physical exertion).

 

Suffocation; if present, define the following points:

           -aura: have been the patient ever noticed any previous symptoms like itching, dyspnea, nasal catarrh, sneezing or other before the attack?

           -When does the attack occur?

           -Patient’s behavior and posture during the attack?

           -Duration, frequency, intensity of attacks;

           -relieving factors (if the patient feels better after usage of medicines - define the form of  usage: inhalations or injections).

 

Digestive system

What is patient’s appetite (good, moderate, increased, lack of appetite,  supressed, deranged, distaste for some kind of food (indicate it), fear of food intake).

Saturation: moderate, quick, permanent, constant feeling of hunger.

Mastication: deranged or preserved, pain at mastication (yes, no).

Does the patient complain of thirst? If yes, indicate its timing (constant or intermittent), when does it occure, relieving factors. The volume of water, drunken per day.

 Salivation: its periodicity (permanent or periodical), duration, when does it occur, relation to food intake, relieving factors.

Dryness in the mouth, pain and burning sensation in the tongue (yes, no).

Taste in the mouth:   normal, sour, bitter, metallic, sweet, deranged, perverted.

Swallowing and passage of food portion through the esophagus (painful, impossible or  difficult (does the difficulty depend on the sort of food – solid, liquid)?

 

Does the patient complain of pain in abdominal region? If yes, define its

           -location;

           -under which conditions does it appear?

           -Relation to the time of food intake (immediatelly after eating, in some minutes, 20-30 min, 40-50 min, in some hours,  “fasting” and “night” pain);

           -to the sort of food (fat, fried, spicy, milk, coarse, sweet) and its amount;

-characteristics of pain: acute, knife-like, dull, burning, boring, girdle, feeling of heaviness in the certain abdominal zone);

           -its intensity (slight, of moderate intensity, strong, severe);

           -irradiation;

           -time relationship (permament, periodical, undulate, seasonal);

           -duration of attacks (during some minutes, hours, days);

           -under what conditions does pain develop or become more intensive?

           -Relieving factors (vomiting, food intake, medications, intake of soda, applying of heat or  cold). In which body position does pain decrease?

           -Associated manifestations (changes of skin color, urine, feces etc.).

 

Nausea: if present, detail the following:

           -does it preceed vomiting or not?

           -Is there any relation of nausea occurence to food intake (yes, no) and the sort of food (if yes, indicate the sort of food)?

 

If the patient complains of vomiting it is necessary to define the following:

           -time of its appearance (on the empty stomach, relation to food intake: immediately after or late). Frequency of occurence, relation to pain;

           -provoking factors; relation to food intake, to the sort of food, relieving factors, does vomiting relieve patient’s condition?

           -Volume and character of emesis (with digested or indigested food, as a coffee ground, with admixtures of fresh blood, bile, mucus, foamy);

           -smell of the vomit if any (ammonia, bitter oil, acid, putrid, fecal, without any smell);

           -does vomiting relieve patient’s condition?

 

Regurgitation: if the patient suffers for, define the following:

           -time of its appearance (immediately after meals, some time after meals, after change of body position, on straining effort etc.);

           -character of regurgitation (gaseous, food, bitter or acid belching, musty smelling);

           -its duration, intensity, relieving factors.

 

In the case of heartburn define the frequency of its attacks,  

           -relation to food intake and the sort of food (immediately afer meals, after change of a position of the body);

           -relieving factors (taking baking soda, water, any drugs etc.).

 

Meteorisms: (present or absent);

           -does the patient feel abdominal murmur, fluctuation? If yes, indicate their location, under what conditions they develop or become more intensive, relation to food intake (indicate the sort of food) and to pain. Relieving factors;

           -passage of gasses through the intestine: free, difficult or impossible. Their smell (acute, putrefied, acid). Relation to food intake, the kind of food and defecation.

 

Stool: define the following:

           -frequency of defecation (frequent, regular, irregular, constipation, after enema);

           -a feeling of incomplete emptying of the bowels after defecation;

           -volume and consistence of stool (formed, fragmentation, semiliquid, ribbon shaped, watery, rie-water);

           -сolour (brown, light, tarry)  and smell of feces;

           -admixtures if any (mucus, blood, pus, helminths, indigested food, foreign bodies);

           -in the case of blood discharging –does it occur during or after defecation; are feces mixed with blood or blood is present on the surface of feces;

           -tenesmus if any.

 

  Itching, anal pains if any: timing, duration, intensity, relation to defecation.

 

Urinary system

Pain in the lumbar region: its  character (dull, aching, acute, colicky);

           -is it permanent or attack-like?

           -Its irradiation, duration;

           -provoking and relieving factors.

 

Urination: define the following:

           -is urination normal or painful?

           -Frequency of urinations per day (general and separately during day- and  night-time);

           -the volume of water taken per day and discharged urina per day; correlation between daily and night diureses;

           -colour of urine (straw-yellow, “meat wastes”, “beer”);

           -smell  of urine;

           -urine sediment (present or absent, colour of sediments).

           Urinary incontinence if any: is it permanent or periodical, in the last case- its provoking factors (laughing,  coughing, drinking water etc.).

 

Endocrine system

Ask patient about the following:

Impairment from normal body growth and (or) fortmation of body build.

Any changes of body weight during last year’s, months (obesity, weight gain or loss, cachexia).

Ask about presence of the following signs: permanent thirst, hunger, dryness in the mouth, frequent urination, profuse urination, skin itching, white discharge, irritability, teafulness, palpitation, tremor of hands, inhibition.

Impairment of initial and secondary sexual signs.

Has the  patient ever noticed any changes of skin (profuse swetting or dryness, red skars, purulent rash of thre skin, “tanny” skin)?

Hair growth pattern:  pathological, excessive, baldness (indicate if any).

Female should be asked about first menstrual period, the duration and regularity of mensrual period, bleeding between periods or during menopause, menstrual cycle disorders, subjective senses associated with menopause (headache, depression, hot flashes). Absence of menses, sterility if any. Evaluation of libido.

 

Musculo-skeletal apparatus

 Pain in joints, bones, muskces: yes, no. If yes, define the following:

           -location; “wandering” pain if any;

           -timing, duration of pain, its intensity;

           -under what conditions does it develop or aggravate: motion, depending on meterological factors etc.;

           -relieving factors;

           -pain in the backbone at motions (in which zones)?

           -Have the patient ever been noticed puffiness of joints or changes of their configuration, any deformations? Changes of skin above joints (reddness, glitter, tension, local rising of skin temperature (indicate the afflicted joint)?

           -Is the patient satisfyed with volume of movements in upper, lower limbs?

           -Joint and vertebral columned stiffness (location, duration, under what conditions does it develop  or aggravate, when does it disappear).

 Nervous system and sensory organs

Does the patient feel headache? If yes, define the character, location, intensity, timing, duration of headache. What factors do relieve or remove it?

Dizziness: when does it occur, its duration, timing, frequency, intensity.

Sleep: its deepness, duration, character of dreams (normal, deep, insomnia). Does the patient sleep well? Any unususal, expressive dreams.

Work capacity: preserved or reduced.

Mood: its changes, excessive erritability, tearfulness, apathy, peculiarities of behavior and speech.

Convulsions, muscular tremor, dizziness, loosing of consciousness (indicate if present). Feeling of weakness in limbs. Deranged sensitivity (parestesias and the like), disorders of gait.

Disorders of sense organs: changes of vision, hearing, smell, taste, desire to eat inedible substances. Noise in the ears if any.

 

Blood system

Pain in bones (indicate its location), in the right or left hypochondrium: when does it occur, its character, time relationship, duration, intensity, provoking and relieving factors.

Bleeding, hemorrhagic rash on the skin and mucous membranes (their location, character, frequency of occurence, duration). Provoking and relieving factors.

Enlargement of perypheric lymph nodes if any: (their location, consistency, painfulness).

Condition of skin and mucous membranes (itching, pain, change of colour, necrotization). Enlargement of the abdomen in the projection of liver and spleen.

 

General complaints (molestia communis): rise of body temperature (indicate the time and limits of its fluctuation during a day, relieving factors); character of fever and its duration. Chills and their frequency. Sweating: its intensity and time of occurrence (night sweating). General indisposition, weakness, fatigue, decreasing of work capacity, other complaints.

 

History of present illness (Anamnesis morbi)

When and  under the what conditions did the first signs of the disease appeare?

What was the beginning (onset) of the disease (acute, gradual) 

What were the first signs of the disease?

What is the main cause of the disease on the patient’s own opinion? What preceded the disease (overcooling, infection, stress, physical examination or other factors)?

Did the first symptoms change in dynamics? Did new symptoms occur from the beginning of the disease till the moment of admission? (rising, aggravation, releising or removing of new symptoms should be described in chronologic sequence).

Did the patient receive any treatment before the admission to the hospital? If yes, what was it (self-treatment, ambulatory or long-standing hospital treatment)? What kind of medicines or another therapeutical agents did the patient receive?

What was the result of previous treatment (did the patient feel him better, worse or without any  changes)?

Have the patient been ever examined before present admission to the hospital? If yes, what are the results of examination?

In the case of chronic disease following should be detalized: the first attack of the disease (its detail describtion – onset, duration, severity etc), course (frequency, duration of exacerbations, results of their treatment, patient’s self-being after treatment and during remissions),  diagnosis, that was made at previous examinations. The last exacerbation should be described literally. Data about course of the disease during present treatment in the hospital should be recorded too (till the moment of the beginning of curation).

Patient’s work-status (medical insurance) before the hospitalization is than clarified as well as  reasons of hospitalization. Dynamics of symptoms after present admitting till the moment of examination is given.

 

 Patient’s life history (Anamnesis vitae)

The main data about patient’s life should be presented in a short form.

Physical and phsychomotor development of the patient in childhood. Progress in studding process at school: what were the skills in theoretical subjects and physical training (excellent, good, bad), the interest for education and contact with school friends, hobby).

The beginning of work activity and following professional way (which professions was the patient dealt with and how long, the kind of activity (physical, mental), labor conditions, probably harmful professional factors). Present labor conditions: strong noise, vibrations, high ambient temperature, draftes, moistness, character of illumination, cold (work in the open), some chemical and radiation agents.

The mode of work activity: duration of work, breaks, holidays, leave. Are there any tensions at work? If any professional disease is suspected professional anamnesis should be taken detailier (see appendix 2).

Material and housing conditions in different periods of patient’s life and nowadays: what is the area of house (flat), which floor does the flat occupy, character of heating, moistness, draftes. Composition of family, family budget, any tensions in the family. How does the patient   spend his leisure time: is it enough time for sleep, rest, walks in the open. Gardening, sport (what kind of sports and exercises does he go in for).

Nutritional mode: regular or irregular feeding, frequency of meals, does the patient eat in the housing conditions or out of home. The character of meals, nutritional habits, dry meals.

Harmful habits: smoking – if yes, indicate, in which age did the patient start to smoke, the quantity of  sigarettes smoked per day, smoking on empty stomach and at night;

-            alkohol consumption - if yes, ask about the following: in which age did the patient start to drink alkohol, how often and how much does he drink, the sort of drink, how does the patient tolerate alkohol;

-            coffeiemania - does the patient drink coffee, if yes - how often and in which day time;

-             drug abuse, toxicomania.

Any diseases, traumas, contusions, wounds in the past - if yes, enumerate all of them in chronological sequence with indication of the following: in which patient’s age did the mentioned above conditions take place, their duration, severity, complications; treatment should be indicated as well.

Special attention should be paid to infectious diseases (thyphus, hepatitis etc.) as well as to veneral diseases, AIDS, tuberculosis in the patient and his relatives. AIDS-risk factors: residence in endemic regions, multiple sexual relations and perversions, repeated hemotransfusions, operations. If there is suspicion on infectious disease - infectious anamnesis should be taken detailier (see appendix 3).

 Family anamnesis:

In female patient it should include the following information:

  -when did the first menstruation (menarche) take place, character of menses (regularity,duration, volume of discharged blood). The age of marriage and beginning of sexual life. Number of pregnancies and their results: abortions, inevitable abortions (in which reason), miscarried fetus, delivery, premature birth, jaundice of newborns;

  -breach of menstrual function: painful, premature, delayed, protracted, excessive menstruations, bloody discharges between menstruations. Inflammation of female reproductive system organs;

  -if menstruation had disappeared (climax), it should be recorded in which patient’s age did it take place, were (are) there any unpleasant feelings during climax (headache, reddening of the face, irritability etc.).

In male patients in should be indicated the following information: breach of descent of testes (monirchodoism, cryptorchism), inflammatory diseases of testes, prostate; sexual problems.

Allergological anamnesis:

Allergic reactions (urticaria, Quincke’s edema, anaphylactic shock etc.) to different kind of food, medicines, industrial or domestic allergens, trees’ blooming, feather etc.  Allergic diseases of relatives. Have any transfusions of blood or blood substitutes been ever given, if yes - has the patient showed any reactions on them?

Genetic anamnesis: Can the patient remind any genetic diseases in his family? What is the state of health or cause of death of close relatives (if somebody of relatives had died – indicate in which age it took place). Has (had) somebody of relatives diabetes mellitus, bronchial asthma or another chronic hereditary-predisposed diseases? Special attention should be paid for diseases with clinical manifestation similar to these in the patient.

 

 

 

 

 

 

 

THE GENERAL EXAMINATION

The setting for a physical examination

Patients attending a general practitioner are seen in the surgery or at home, whereas hospital examinations take place in outpatient clinic rooms or on the wards. Privacy is essential but may be difficult in a ward setting. Pulling the curtains around the bed obscures vision but not sound, it is therefore important to talk with the patient quietly but at a level sufficient for good communication. This may be difficult with deaf, elderly patients.

Perform the physical examination in a warm and well-lit environment. Subtle abnormalities of complexion, such as mild jaundice, are easier to detect in natural rather than artificial light. The examination couch or bed should be of adjustable height, with a step or stool to allow patients to get up easily. An adjustable backrest is essential, particularly for breathless patients who cannot lie flat. Sensitively, but adequately, expose the areas of the body to be examined and cover the rest of the patient with a blanket or sheet. Take care to avoid unnecessary exposure and embarrassment. A female patient will appreciate the opportunity to replace her brassiere after you have completed the chest examination and before you examine her abdomen. Make sure your patient does not become cold during the examination.

Tactfully ask relatives to leave the room before the physical examination. Sometimes it is appropriate for one to remain if the patient is very apprehensive, or if you need a translator or if the patient requests it. Parents should always be present when you examine small children. For any intimate examination you should have a chaperone to prevent misunderstandings and provide support and encouragement for the patient. Some patients do not wish this; respect their wishes and record it in the notes.

Sequence for performing a physical examination

With experience, you will develop your own style and sequence of physical examination. A regular routine helps to reduce the chance of you missing things out.

The sequence of examination is:

Inspection

Palpation

Percussion

Auscultation

You will learn to integrate these smoothly into each component of the physical examination, sometimes combining two or more. There is no single correct way of performing a physical examination.

Assess patient’s bearing and gate

 

General examination of a patient

 

Despite the many instrumental and laboratory tests available at the present time, general inspection of the patient (inspectio) has remained an im­portant diagnostic procedure for any medical specialist. The patient's condition on the whole can be assessed and a correct diagnosis can sometimes be made at "first sight" (acromegaly, toxic goitre, etc.). Pathological signs revealed during inspection of the patient are of great help in collecting an anamnesis and in further studies. In order to make the best possible inspection, the following special rules should be followed, which concern illumination during inspection, its technique and plan.

Illumination. The patient should be examined in the daytime, because electric light will mask any yellow colouring of the skin and the sclera. In addition to direct light, which outlines the entire body and its separate parts, side light will also be useful to reveal pulsation on the surface of the body (the apex beat), respiratory movements of the chest, peristalsis of the stomach and the intestine. Tangential (side) light is also useful for recognition of rushes and outpochings.

Inspection technique. The body should be inspected by successively un­covering the patient and examining him in direct and side light. The trunk and the chest are better examined when the patient is in a vertical posture. When the abdomen is examined, the patient may be either in the erect (upright) or supine (dorsal or recumbent) position. The examination should be carried out according to a special plan, since the physician can miss important signs that otherwise could give a clue for the diagnosis (e.g. liver palm or spider angiomata which are characteristic of cirrhosis of the liver).

The entire body is first inspected in order to reveal general symptoms. Next, separate parts of the body should be examined: the head, face, neck, trunk, limbs, skin, bones, joints, mucosa, and the hair cover. The general condition of the patient is characterized by the following signs: consciousness and the psyche, posture, gait and body-built.

 

Anatomical, physiological and clinical peculiarities of different stages of consciousness disorders and their diagnostic value

Patient’s consciousness may be clear or deranged. Depending on the degree of disorder, the following psychic states are differentiated.

1. Stupor. The patient cannot orient himself to the surroundings, he gives delayed answers. The state is characteristic of contusion and in some cases poisoning.

2. Sopor. This is an unusually deep sleep from which the patient recovers only for short periods of time when called loudly, or roused by an external stimulus. The reflexes are preserved. The state can be observed in some infectious diseases and at the initial stage of acute uraemia.

3. Coma. The comatose state is the full loss of consciousness with complete absence of response to external stimullation, with the absence of reflexes, and deranged vital functions. The causes of coma are quite varied but the loss of consciousness in coma of any aetiology is connected with the cerebral cortex dysfunction caused by some factors, among which the most important are disordered cerebral circulation and anoxia. Oedema of the brain and its membranes, increased intracranial pressure, effect of toxic substances on the brain tissue, metabolic and hormone disorders, and also upset acid-base equilibrium are also very important for the onset of coma. Coma may occur suddenly or develop gradually, through various stages of consciousness disorders. The period that precedes the onset of a complete coma is called the precomatose state. The following forms of coma are most common.

Alcoholic coma. The face is cyanotic, the pupils are dilated, the respiration shallow, the pulse low and accelerated, the arterial pressure is low; the patient has alcohol on his breath.

Apoplexic coma (due to cerebral haemorrhage). The face is red, breathing is slow, deep, noisy, and the pulse is full and rare.

Hypoglycaemic coma can develop during insulin therapy for diabetes.

Diabetic {hyperglycaemic) coma occurs in non-treated diabetes mellitus.

Hepatic coma develops in acute and subacute dystrophy and necrosis of the liver parenchyma, and at the final stage of liver cirrhosis.

Uraemic coma develops in acute toxic and terminal stages of various chronic diseases of the kidneys.

Epileptic coma. The face is cyanotic, there are clonic and tonic convulsions and the tongue is bitten. Uncontrolled urination and defecation. The pulse is frequent, the eye-balls are moved aside, the pupils are dilated and breathing is hoarse.

4. Irritative disorders of consciousness may also develop. These are characterized by excitation of the central nervous system in the form of hallucinations, delirium (delirium furibundum due to alcoholism; in pneumonia, especially in alcoholics; quiet delirium in typhus, etc.).

General inspection can also give information on other psychic disorders that may occur in the patient (depression, apathy).

Patient’s posture, bearing and gait

Posture of a patient can be active, passive, or forced.

The patient is active if the disease is relatively mild or at the initial stage of a grave disease. The patient readily changes his posture depending on circumstances. But it should be remembered that excessively sensitive or alert patients would often lie in bed without prescription of the physician.

 

Forced posture is often assumed by the patient to relieve or remove pain, cough, dyspnoea. For example, the sitting position relieves ortho-pnoea: dyspnoea becomes less aggravating in cases with circulatory insufficiency.

 

Patient with emphysema bending over in Tri-Pod Position

 The relief that the patient feels is associated with the decreased volume of circulating blood in the sitting position (some blood remains in the lower limbs and the cerebral circulation is thus improved). Patients with dry pleurisy, lung abscess, or bronchiectasis prefer to lie on the affected side. Pain relief in dry pleurisy can be explained by the limited movement of the pleural layers when the patient lies on the affected side. If a patient with lung abscess or bronchiectasis lies on the healthy side, coughing intensifies because the intracavital contents penetrate the bronchial tree. And quite the reverse, the patient cannot lie on the affected side if the ribs are fractured because of pain intensifies if the affected side is pressed against the bed. The patient may sit inclining slightly forward if fluid is accumulated in the pericardium.

The patient with cerebrospinal meningitis would usually lie on his side with his head thrown back and the thighs and legs flexed on the abdomen. Patients with angina pectoris and intermittent claudication prefer to stand upright. The patient is also erecting (standing or sitting) during attacks of bronchial asthma. He would lean against the edge of the table or the chair back, with the upper part of the body slightly inclined forward. Auxiliary respiratory muscles are more active in this posture. The supine posture is characteristic of strong pain in the abdomen (acute appendicitis, perforated ulcer of the stomach or duodenum). The prone position (lying with the face down) is characteristic of patients with tumours of the pancreas and gastric ulcer (if the posterior wall of the stomach is affected). Pressure of the pancreas on the solar plexus is lessened in this posture. In rheumatic arthritis patient gains a forced supine posture; patient may be in prone position if his spine is affected.

Some patients change their posture frequently because previous posture doesn’t relieve their pain.

Passive posture is observed with unconscious patients or, in rare cases, with extreme asthenia. The patient is motionless, his head and the limbs.

The posture or attitude of the patient is often indicative of his general tone, the degree of muscle development, and sometimes of his occupation and habits. Most patients with grave diseases or with psychic depression are often stooped. Active posture, erect bearing, easy gait, and free and unconstrained movements indicate the normal condition of the body. Some gaits are specific for certain diseases of the nervous system (hemyplegia, sciatica, etc.). Surgical diseases of the bones and joints, rheumatism, or deranged blood circulation in the lower extremities change the gait and bearing and make walking difficult. The so-called waddling gait is characteristic of osteomalacia or congenital dislocation of the femur.

 

Anthropometric examination of a patient. The types of body built (constitution), their characteristic and classification

The concept of habitus includes the body-build, i.e. constitution, height, and body weight.

The methods and techniques used to assess the morphological condi­tions of man are called anthropometry (Gk anthropos man and metron measure).

The height of the patient is measured by a simple device which is actually a vertical plank graduated in centimetres along which a horizontal piece slides. The patient stands upright on the platform, his heels, buttocks and shoulder blades touching the vertical plank.

The head should be held in a position in which the auditory meatus is level with the lateral edge of the eye. The horizontal piece is then lowered to touch the head and the patient's height is read off the plank.

The patient is weighed on medical scales. His weight is determined up on admittance and not less than once a week during his stay at the hospital. The patient should be weighed in his underwear in the morning before breakfast, after urination and emptying the bowels. A normal weight is found by subtracting 100 from the height (in sm). This is only a tentative method since normal weight varies with age and for many other factors. The patient usually loses weight in many diseases, especially those associated with malig­nant newgrowths, tuberculosis, acute infections, and gastrointestinal diseases. Fat tissue is lost first and then the patient loses weight at the expense of muscular tissues. Patients with oedema gain weight due to retention of moisture in the tissues.

The girth of the chest is measured by a tape passed under the angles of the shoulder blades on the back and across the 4th rib of the chest. The girth should be measured with quiet breathing and hanging hands freely at the patient's sides. The measurements are taken at the height of inspiration and expiration.

 

 

Constitution (L constituero to set up) is the combination of functional and morphological bodily features that are based on the inherited and ac­quired properties, and that account for the body response to endo- and exogenic factors. The classification by M. Chernorutsky differentiates between the following three main constitutional types: asthenic, hypersthenic, and normosthenic.

 

 The asthenic constitution is characterized by a considerable predominance of the longitudinal over the transverse dimensions of the body by the dominance of the limbs over the trunk, of the chest over the abdomen. The heart and the parenchymatous organs are relatively small, the lungs are elongated, the intestine is short, the mesenterium long, and the diaphragm is low. Arterial pressure is lower than in hypersthenics; the vital capacity of the lungs is greater, the secretion and peristalsis of the stomach, and also the absorptive power of the stomach and intestine are decreased; the haemoglobin and red blood cells counts, the level of cholesterol, calcium, uric acid, and sugar in the blood are also decreased. Adrenal and sexual functions are often decreased along with thyroid and pituitary hyperfunction.

The hypersihenic constitution is characterized by the relative predominance of the transverse over the longitudinal dimensions of the body (compared with the normosthenic constitution). The trunk is relatively long, the limbs are short, the abdomen is large, and the diaphragm stands high. All internal organs except the lungs are larger than those in asthenics. The intestine is longer, the walls are thicker, and the capacity of the in­testine is larger. The arterial pressure is higher; haemoglobin and red blood cell count and the content of cholesterol are also higher; hypermobility and hypersecretion of the stomach are more normal. The secretory and the absorptive function of the intestine are high. Thyroid hypofunction is common, while the function of the sex and adrenal glands is slightly increased.

Normosthenic constitution is characterized by a well proportioned make-up of the body and is intermediate between the asthenic and hypersthenic constitutions.

For more objective estimation of proportionaloty of patient’s body-build the following indicies are used:

1. The statural-weight value (Bushar’s index):

Bw х 100

      H        ;

Where H is patient’s heighth, Bw – patient’s body weight. Normal indicies are within 37-40. Lower index indicates malnutrition, higher – overfeeding.

2. The index of proportionality between height and the girth (circumference) of the chest (Broogch’s index):

H х 100

          G,

Where H - patient’s heighth, G - the girth of the chest. Normal indicies are within 50-55. Lower figures indicate narrow chest (sthenothorax), higher – broad chest.

3. The ratio between these 3 indicies (Pinjette’s index):

 H- (G + Bw).

Norm is about 20 and deviates significantly if this proportion is abnormal.

 

The posture or attitude of the patient is often indicative of his general tone, the degree of muscle development, and sometimes of his occupation and habits. Most patients with grave diseases or with psychic depression are often stooped. Erect posture, easy gait, and free and unconstrained movements indicate the normal condition of the body. Some gaits are specific for certain diseases of the nervous system (hemiplegia, sciatica, etc.) Surgical diseases of the bones and joints, rheumatism, or deranged blood circulation in the lower extremities change the gait and make walking difficult. The so-called waddling gait is characteristic of osteomalacia or u'enital dislocation of the femur.

 During the general inspection, the physician should pay attention to the open parts of the patient's body, the head, the face and the neck.

Changes in the size and shape of the head can give diagnostic clues. Excessive growth of the skull occurs in hydrocephalus. An abnormally small is typical of microcephalus, which is also marked by mental underdevelopment. A square head, flattened on top, can indicate congenital syphilis or rickets in past history. The position of the head is also important in diagnosing cervical myositis or spondylarthritis.  Involuntary movements of the head (tremor) are characteristic for Parkinsonism. Rhythmical movements of the head in synchronism with the cardiac pulse are characteristic of aortic incompetence (Musset's sign). The presence of scars on the head may suggest the cause of persistent headache. It is necessary to find out whether the patient has vertigo tigo which is typical particularly for Meniere's syndrome, or epileptiform attacks.

Countenance. The facial expression can indicate the mental composure and various psychic and somatic conditions. It also depends on age and sex and can therefore give diagnostic clues when diagnosing some endocrine disorders (woman-like expression in men and masculine features in women). The following changes in the face are diagnostically essential:

1. A puffy face is observed in (a) general oedema characteristic of renal diseases; (b) local venous congestion in frequent fits of suffocation and cough; (c) compression of lymph ducts in extensive effusion into the pleural and pericardial cavity, in tumours of mediastinum, enlarged mediastinal lymph nodes, adhesive mediastinopericarditis, compressed superior vena cava (Stokes' collar).

 2. Corvisart's facies is characteristic of cardiac insufficiency. The face is oedematous, pale yellowish, with a cyanotic hue. The mouth is always half open, the lips are cyanotic, the eyes are dull and the eyelids sticky.

3. Facies febrilis is characterized by hyperaemic skin, sparkling eyes and excited expression. There are special features of facies febrilis characteristic of some infectious diseases: feverish redness in acute lobar pneumonia (more pronounced on the side of the affected lung); general hyperaemia of the puffy face is characteristic of louse-borne typhus, the sclera is injected ("rabbit eye" according to F. Yankovsky); slightly icteric yellow colour is characteristic of typhoid fever. Tuberculosis patients with fever have "burning" eyes on an exhausted and pale face with blush localized on the cheeks. An immobile face is characteristic of septic fever; the face is pale, sometimes slightly yellowish.

4. Face and its expression are altered in various endocrine disorders;

(a) a face with enlarged promient parts (such as nose, chin, and cheek bones) and enlarged hands are characteristic of acromegalia (hands become enlarged in some pregnancies);

(b) myxoedematous face indicates thyroid hypofunction; the face may be uniformly puffy with oedematous mucosa, narrowed eye slits, the face features smoothed down, the hair is absent on the outward portions of the eyebrow; the presence of a blush on a pale face resembles the appearance of a doll;

(c) facies basedovica this is the face of a patient with thyroid hyperfunction; the face is lively with widened eye slits and abnormally sparkling eyes; the eyes are protruded and the face looks as if frightened;

d) an intense red, moon-like glittering face with a beard and mustaches in women is characteristic of the Itsenko-Cushing disease.

5. Facies leontina with nodular thickening of the skin under the eyes and over the brows, with flattened nose is observed in leprosy.

6. Parkinson’s mask (or facies) is an amimic face characteristic of encephalitis patients.

7. A slightly puffy wax-doll, very pale face with a yellowish tint, and seemingly translucent skin, is characteristic of Addison-Biermer anaemia.

8. Risus sardonicus with a semblance of a grin occurs in tetanus patients: the mouns widens as in laughter, while the skin folds on the forehead express grief.

9. Facies hippocratica (first described by Hippocrates) is associated with collapse in grave diseases of the abdominal organs (diffuse peritonitis, perforated ulcer of the stomach or duodenum, rupture of the gall bladder).

10. Asymetric movements of facial muscles indicate a history ofcerebral haemorrhage or facial neuritis.

11. Face in sclerodermia is amimic, moth os narrowed, skin is stretched:

 

Inspection of the eyes and eyelids can reveal some essential diagnostic signs. Oedema of the eyelids, especially of the lower eyelids, is the first in­dication of acute nephritis; it is also observed in anaemia, frequent attacks of cough, and deranged sleep; oedema of the eyelids can also occur in the morning in healthy persons as well.

The colour of the eyelids is important. The eyelids are dark in diffuse toxic goitre and Addison disease. Xanthomas indicate deranged cholesterol metabolism.

 

 

 

Xanthelasma: Yellow deposits apparent above and below eyes, due to infiltration with fat laden cells. This is frequently assoicated with severe hypercholesterolemia.

 A dilated eye slit with the eyelids that do not close is characteristic of paralysis of the facial nerve; persistent drooping of the up­per eyelid (ptosis) is an important sign of some affections of the nervous system. Narrowing of the eye slit occurs in myxoedema and general oedema of the face. Exophthalmos (protrusion of the eyeball) is observed in thyrotoxicosis, retrobulbar tumours, and also in strong myopia. Reces­sion of the eyeball in the orbit (enophthalmos) is typical of myxoedemaand is an important sign of "peritoneal face". Unilateral recession of the eye into the orbit attended by narrowing of the eye slit, drooping of the upper eyelid and narrowing of the pupil, is the Homer's (Bernard-Horner) sydrome caused by the affection of the pupil sympathetic innervation of the same side (due to various causes).

 

The shape of the pupils, their symmetry, response to light, accommodation and convergence, and also their "pulsation" are of great diagnostic significance in certain diseases. Abnormally contracted pupil (miosis) is observed in uraemia, tumours and intracranial haemorrhages, and inmor-phine poisoning. Enlargement of the pupil (mydriasis) occurs in comatose states (except uraemic coma) and cerebral haemorrhages, and also in atropine poisoning. Anisocoria (unequal size of the pupils) occurs in some affections of the nervous system. Squinting results from paralysis of the ocular muscles due to lead poisoning, botulism, diphtheria, affections of the brain and its membranes (syphilis, tuberculosis, meningitis, cerebral haemorrhage).

Sclera: The normal sclera is white and surrounds the iris and pupil. In the setting of liver or blood disorders that cause hyperbilirubinemia, the sclera may appear yellow, referred to as icterus. This can be easily confused with a muddy-brown discoloration common among older African Americans that is a variant of normal.

Icteric Sclera

 

Muddy Brown Sclera

Conjunctiva: The sclera is covered by a thin transparent membrane known as the conjunctiva, which reflects back onto the underside of the eyelids. Normally, it's invisible except for the fine blood vessels that run through it. When infected or otherwise inflamed, this layer can appear quite red, a condition known as conjunctivitis. Alternatively, the conjunctiva can appear pale if patient is very anemic. By gently applying pressure and pulling down and away on the skin below the lower lid, you can examine the conjunctival reflection, which is the best place to identify this finding.

 

Normal Appearing Conjunctival Reflection, Lower Lid

Pale Conjunctiva, due to severe anemia.

1.    

2.     Conjunctivitis

Blood can also accumulate underneath the conjunctiva when one of the small blood vessels within it ruptures. This may be the result of relatively minor trauma (cough, sneeze, or direct blow), a bleeding disorder or idiopathic. The resulting collection of blood is called a subconjunctival hemorrhage. While dramatic, is generally self limited and does not affect vision.

3.     Subconjunctival Hemorrhage

 

 

 

 

Herpes labialis

Skin eruption (roseola)

Skin eruption (erythema)

 

 

Boldness (general and local)

 

The size of the nose may attract attention providing some diagnostic signs, e.g. it has an abnormal size in acromegaly, or its shape deviates from the normal in rhinoscleroma. The nose may be sunken as a result of syphilis in the past history (saddle nose). Soft tissues of the nose are disfigured in lupus.

When inspecting the mouth attention should be paid to it’s shape (sym­metry of the angles, permanently open mouth), the colour of the lips, erup­tion on the lips (cold sores, herpes labialis), and the presence of fissures. The oral mucosa should also be inspected (for the presence of aphthae, pigmentation, Filatov-Koplik spots, thrush, contagious aphthae of the fooi and mouth disease, haemorrhage). Marked changes in the gums can be I observed in some diseases (such as pyorrhoea, acute leykaemia, diabetes mellitus, and scurvy) and poisoning (with lead or mercury). The teeth I should be examined for the absence of defective shape, size, or position! The absence of many teeth is very important in the aetiology of somcl alimentary diseases. Caries is the source of infection and can affect some other organs.

Disordered movement of the tongue may indicate nervous affections, grave infections and poisoning. Marked enlargement of the tongue is characteristic of myxoedema and acromegaly; less frequently it occurs in glossitis. Some diseases are characterized by the following abnormalities of the tongue: (1) the tongue is clear, red, and moist in ulcer; (2) crimson-red in scarlet fever; (3) dry, with a brown coat and grooves in grave poisoning and infections; (4) coated in the centre and at the root, but clear at the tip and margins in typhoid fever; (5) smooth tongue without papillae (as polished) is characteristic of Addison-Biermer disease. The glassy tongue is characteristic of gastric cancer, pellagra, sprue, and ariboflavinosis; (6) local thickening of the epithelium is characteristicof smokers (leucoplakia). Local pathological processes, such as ulcers of various aetiology, scars, traces left from tongue biting during epileptic fits, ets, are also suggestive of certain diseases.

Examination of the tongue is useful in diagnostics of the following conditions:

1. Irritation (pointer medial fold).
2. Spinal cord deviation in lumbar region.
3. Spinal cord deviation in thopracic region.
4. Spinal cord deviation in cervical region.
5. Chronic enterocolitis, dyspepsia (teeth signs on the lateral parts of the tongue).
6. Thyrotoxicosis, neurasthenia, alkoholism (tremor of the tongue).
7. Chronic disease of the large bowel (a lot of amall folds).
8. Kidney disfunction.
9. Large bowel disfunction.
10. Intoxication generates in the large bowel.
11. Intoxication generates in gastrointestinal tract.
12. Cardiac disfunction.
13. Chronic bronchitis.
14. Pneumonia folloved by intoxication (brown coating).
15. Pulminary emphysema.

 

Coated tongue

Skin depigmentation (vitiligo)

 

 

 

During inspection of the neck attention should be paid to pulsation of the carotid artery (aortic incompetence, thyrotoxicosis), swelling andpulsation of the external yugular veins (tricuspid valve insufficiency), enlarged lymph nodes (tuberculosis, lympholeukaemia, lymphogranulomatosis and cancer metastases), diffuse or local enlargement of thethyroid gland (thyrotoxicosis, simple goiter, malignant tumour).

 

 

Lymph Nodes: The major lymph node groups are located along the anterior and posterior aspects of the neck and on the underside of the jaw. If the nodes are quite big, you may be able to see them bulging under the skin, particularly if the enlargement is asymmetric (i.e. it will be more obvious if one side is larger then the other). To palpate, use the pads of all four fingertips as these are the most sensitive parts of your hands. Examine both sides of the head simultaneously, walking your fingers down the area in question while applying steady, gentle pressure. The major groups of lymph nodes as well as the structures that they drain are listed below. The description of drainage pathways are rough approximations as there is frequently a fair amount of variability and overlap. Nodes are generally examined in the following order:

 

Palpating Anterior Cervical Lymph Nodes

1. Anterior Cervical (both superficial and deep): Nodes that lie both on top of and beneath the sternocleidomastoid muscles (SCM) on either side of the neck, from the angle of the jaw to the top of the clavicle. This muscle allows the head to turn to the right and left. The right SCM turns the head to the left and vice versa. They can be easily identified by asking the patient to turn their head into your hand while you provide resistance. Drainage: The internal structures of the throat as well as part of the posterior pharynx, tonsils, and thyroid gland.

 

 

 

2.     Posterior Cervical: Extend in a line posterior to the SCM but in front of the trapezius, from the level of the mastoid bone to the clavicle. Drainage: The skin on the back of the head. Also frequently enlarged during upper respiratory infections (e.g. mononucleosis).

3.     Tonsillar: Located just below the angle of the mandible. Drainage: The tonsilar and posterior pharyngeal regions.

4.     Sub-Mandibular: Along the underside of the jaw on either side. Drainage: The structures in the floor of the mouth.

5.     Sub-Mental: Just below the chin. Drainage: The teeth and oral cavity.

6.     Supra-clavicular: In the hollow above the clavicle, just lateral to where it joins the sternum. Drainage: Part of the throacic cavity, abdomen.

 A number of other lymph node groups exist. However, palpation of these areas is limited to those situations when a problem is identified in that specific region (e.g. the pre-auricular nodes, located in front of the ears, may become inflamed during infections of the external canal of the ear).

   Lymph nodes are part of the immune system. As such, they are most readily palpable when fighting infections. Infections can either originate from the organs that they drain or primarily within the lymph node itself, referred to as lymphadenitis. Infected lymph nodes tend to be:

• Firm, tender, enlarged and warm. Inflammation can spread to the overlying skin, causing it to appear reddened.

If an infection remains untreated, the center of the node may become necrotic, resulting in the accumulation of fluid and debris within the structure. This is known as an abscess and feels a bit like a tensely filled balloon or grape (fluctuance). Knowledge of which nodes drain specific areas will help you search efficiently. Following infection, lymph nodes occasionally remain permanently enlarged, though they should be non-tender, small (less then 1 sm), have a rubbery consistency and none of the characteristics described above or below. It is common, for example, to find small, palpable nodes in the submandibular/tonsilar region of otherwise healthy individuals. This likely represents sequelae of past pharyngitis or dental infections.

Malignancy may also involve the lymph nodes, either primarily (e.g. lymphoma) or as a site of metastasis. In either case, these nodes are generally:

 

Lymph nodes of the head and neck

• Firm, non-tender, matted (i.e. stuck to each other), fixed (i.e. not freely mobile but rather stuck down to underlying tissue), and increase in size over time.

The location of the lymph node may help to determine the site of malignancy. Diffuse, bilateral involvement suggests a systemic malignancy (e.g. lymphoma) while those limited to a specific anatomic region are more likely associated with a local problem. Enlargement of nodes located only on the right side of the neck in the anterior cervical chain, for example, would be consistent with a squamous cell carcinoma, frequently associated with an intra-oral primary cancer.

 

 Cervical Adenopathy: Massive right side cervical adenopathy secondary to metastatic squamous cell cancer originating from this patient's oropharynx.

Cervical Adenopathy: Right anterior cervical adenopathy secondary to metastatic cancer

Diffuse upper airway infections (e.g. mononucleosis), systemic infections (e.g. tuberculosis) and inflammatory processes (e.g. sarcoidosis) can also cause lymphadenopathy (i.e. lymph node enlargement). This can be either symmetric or asymmetric. Historical information as well findings elsewhere in the body are critical to making these diagnoses. Furthermore, it may take serial examinations over the course of weeks to determine whether a node is truly enlarging, suggestive of malignancy, or responding to therapy the passage of time and regressing in size, as might occur with other inflammatory processes.

The parotid glands are located in either cheek. Infection will cause pain and swelling in this area, which can be confirmed on palpation. The ducts which drain the parotids enter the mouth in line with the lower molars and are readily visible. When infected, you may be able to express pus from the ducts by gently palpating the gland.

Right parotid mass. Note enlargement on right  compared with left.

The Thyroid Exam

Prior to palpation, look at the thyroid region. If the gland is quite enlarged, you may actually notice it protruding underneath the skin. To find the thyroid gland, first locate the thyroid cartilage (a.k.a the Adams Apple), which is a mid-line bulge towards the top of the anterior surface of the neck. It's particularly prominent in thin males, sits atop the tracheal rings, and can be seen best when the patient tilts their head backwards. Deviation to one side or the other is usually associated with intra-thoracic pathology. For example, air trapped in one pleural space (known as a pneumothorax) can generate enough pressure so that it collapses the lung on that side, causing mediastinal structures, along with the trachea, to be pushed towards the opposite chest. This deviation may be visible on inspection and can be accentuated by gently placing your finger in the top of the thyroid cartilage and noting its position relative to the midline. The thyroid gland lies approximately 2-3 sm below the thyroid cartilage, on either side of the tracheal rings, which may or may not be apparent on visual inspection. If you're unsure, give the patient a glass of water and have them swallow as you watch this region. Thyroid tissue, along with all of the adjacent structures, will move up and down with swallowing. The normal thyroid is not visible, so it's not worth going through this swallowing exercise if you don't see anything on gross inspection.

 

Location of the Thyroid

Palpation: The thyroid can be examined while you stand in front of or behind the patient. Exam from behind the patient is described below:

1.     Stand behind the patient and place the middle three fingers of either hand along the mid-line of the neck, just below the chin. Gently walk them down until you reach the top of the thyroid cartilage, the first firm structure with which you come into contact. Use gentle pressure, otherwise this can be uncomfortable. Make sure that you tell your patients what you're doing so they know you're not trying to choke them! The cartilage has a small notch in its top and is approximately 1.5-2 sm in length. As you cannot actually see the area that you're examining, it may be helpful to practice in front of a mirror. You can also try to identify and feel the structures from the front while looking at the area in question before performing the exam from behind.

2.     Walk down the thyroid cartilage with your fingers until you come to the horizontal groove which separates it from the cricoid cartilage (the first tracheal ring). You should be able to feel a small indentation (it barely accepts the tip of your finger) between these 2 structures, directly in the mid-line. This is the crico-thyroid membrane, the site for emergent tracheal access in the event of upper airway obstruction.

3.     Continue walking down until you reach the next well defined tracheal ring. Now slide the three fingers of both hands to either side of the rings. The thyroid gland extends from this point downwards for approximately 2-3 sm along each side. The two main lobes are connected by a small isthmus that reaches across mid-line and is almost never palpable. Apply very gentle pressure when you palpate as the normal thyroid tissue is not very prominent and easily compressible. If you're unsure or wish confirmation, have the patient drink water as you palpate. The gland should slide beneath your fingers while it moves upward along with the cartilagenous rings. It takes a very soft, experienced touch in order to actually feel this structure, so don't be disappointed if you can't identify anything.

Thyroid Examination

 

4.     Pay attention to several things as you try to identify the thyroid: If enlarged (and this is a subjective sense that you will develop after many exams), is it symmetrically so? Unilateral vs. bilateral? Are there discrete nodules within either lobe? If the gland feels firm, is it attached to the adjacent structures (i.e. fixed to underlying tissue consistent with malignancy) or freely mobile (i.e. moves up and down with swallowing)? If there is concern re: malignancy, a careful lymph node exam (described above) is important as this is the most common site of spread.

1.     Changes of skin properties (colour, moisture, turgor) in different pathological conditions.

The colour, elasticity, and moisture of the skin, eruptions and scars are important. The colour of the skin depends on the blood filling of cutaneous vessels, the amount and quality of pigment, and on the thickness and translucency of the skin. Pallid skin is connected with insufficiency of blood circulation in the skin vessels due to their spasms of various aetiology or acute bleeding, accumulation of blood in dilated vessels of the abdominal cavity in collapse, and in anaemia. In certain forms of anaemia, the skin is specifically pallid: with a characteristic yellowish tint in Addison-Biermer anaemia, with a greenish tint in chlorosis, earth-like in malignant anaemia, brown or ash-coloured in malaria, “cafe au lait” in subacute septic endocarditis. Pallid skin can also be due to its low translucency and considerable thickness; this is only apparent anaemia, and can be observed in healthy subjects.

Red colour of the skin can be transient in fever or excess exposure to heat: persistent redness of the skin can occur in subjects who are permanently exposed to high temperatures, and also in erythraemia. Cyanotic itch can be due to hypoxia in chronic pulmonary diseases etc. Yellowish colour of the skin and mucosa can be due to upset secretion of bilirubin by the liver or due to increased haemolysis. Dark red or brown skin is characteristic of adrenal insufficiency. Hyperpigmentation of the breast nipples and the areola in women, pigmented patches on the face and the white line on the abdomen are signs of pregnancy. When silver preparations are taken for a long time, the skiri becomes grey on the open parts of the body (argyria). Foci of depigmentation of the skin (vitiligo) also occur.

The skin can be wrinkled due to the loss of elasticity in old age, in prolonged debilitating diseases and in excessive loss of water.

Elasticity and turgor of the skin can be determined by pressing a fold of skin (usually on the abdomen or the extensor surface of the arm) between the thumb and the forefinger. The fold disappears quickly on normal skin when the pressure is released while in cases with decreased turgor, the fold persists for a long period of time.

Moist skin and excess perspiration are observed in drop of temperature in patients recovering from fever and also in some diseases such as tuberculosis, diffuse toxic goitre, malaria, suppuration, etc. Dry skin can be due to a great loss of water, e.g. in diarrhoea or persistent vomiting (toxicosis of pregnancy, organic pylorostenosis).

Eruptions on the skin vary in shape, size, colour, persistence, and spread. The diagnostic value of eruptions is great in some infections such as measles, German measles, chicken- and smallpox, typhus, etc.

 

Erruption due to medication allergy.

 

Roseola is a rash-like eruption of 2-3 mm patches which disappears when pressed. This is due to local dilatation of the vessels. Roseola is a characteristic symptom of typhoid fever, paratyphus, louse-borne typhus, and syphilis.

Desquamation of the skin is of great diagnostic value. It occurs in debilitating diseases and many skin diseases. Scars on the skin, e.g. on the abdomen and the hips, remain after pregnancy (striae gravidarum), in Itsenko-Cushing disease, and in extensive oedema. Indented stellar scars, tightly connected with underlying tissues, are characteristic of syphilitic affections. Postoperative scars indicate surgical operations in past history.

 

 

 

 

Acanthosis Nigricans: Velvety appearing, hyperpigmented skin. Associated with diabetes and a   number of other disorders. Multiple skin tags also seen in this picture of the axillary region.

 

Cirrhosis of the liver is often manifested by development of specific vascular stellae (telangiectasia). This is a positive sign of this disease.

Abnormal growth of hair is usually due to endocrine diseases. Abnormally excessive growth of hair (hirsutism, hypertrichosis) can be congenital, but more frequently it occurs in adrenal tumours (Itsenko-Cushing sydrome) and tumours of the sex glands. Deficient hair growth is characteristic of myxoedema, liver cirrhosis, eunuchoidism, and infantilism. Hair is also affected in some skin diseases.

Nails become excessively brittle in myxoedema, anaemia and hypovitaminosis, and can also be found in some fungal diseases of the skin. Flattened and thickened nails are a symptom of acromegaly. Nails become rounded and look like watch glass in bronchiectasis, congenital heart diseases and some other affections.

      a.       Clubbing: Bulbous appearance of the distal phalanges of all fingers along with concurrent loss of the normal angle between the nail base and adjacent skin. This is most commonly associated with conditions that cause chronic hypoxemia (e.g. severe emphysema), though it is also associated with a number of other conditions. However, in general it is neither common nor particularly sensitive for hypoxia, as most hypoxic patients do not have clubbing.

b.     Cyanosis: A bluish discoloration visible at the nail bases in select patient with severe hypoxemia or hypoperfusion. As with clubbing, it is not at all sensitive for either of these conditions.

 

 

                   Paronychia: Infection of skin adjacent to nail    Onychomycosis: Fungal Infection of the nail of middle finger.                        .

                                                         

    

Figure 1: Clubbing         Figure 2:  Koilonychia         Figure 3: Dupuytren’s

Subcutaneous fat, its development and distribution

Subcutaneous fat can be normal or to various degrees excessive or deficient. The fat can be distributed uniformly or deposited in only certain pans of the body. Its thickness is assessed by palpation. Excessive accumulation of subcutaneous fat (adiposis) can be due to either exogenic (overfeeding, hypodynamia, alcoholism, etc.) or endogenic factors (dysfunction of sex glands, the thyroid, or pituitary gland). Insufficient accumulation of subcutaneous fat may result from constitutional factors (asthenic type), malnutrition, or alimentary dysfunction. Excessive wasting is referred to as cachexia, and may occur in prolonged, intoxication, chronic infections (tuberculosis), malignant newgrowths, diseases of-the pituitary, thyroid and pancreas, and in some psychological disorders as well. Weighing the patient gives additional information about his diet and is an objective means in following up on the patient's weight changes during the treatment of obesity or cachexia.

Checking the degree of subcutaneous fat development can be performed by making a skin fold in patient’s interscapular region between the tumb and the forefinger of physitian arm. Normal width of the fold is about 2 sm, dereases in malnutrition and is sicker in obesity.

Obecity

 

Edema, their localisation, methods of determination

Oedema can be caused by penetration of fluid through the capillary walls and its accumulation in tissues. Accumulated fluid may, be congestive (transudation) or inflammatory (exudation). Local oedema is a result of some local disorders in the blood or lymph circulation; it is usually associated with thrombosis of the veins, that is, compression of the veins by tumours or enlarged lymph nodes. General oedema associated with diseases of the heart, kidneys or other organs is characterized by general distribution of oedema throughout the entire body (anasarca) or by sym­metrical localization in limited regions of the body. These phenomena can be due to the patient lying on one side. If oedema is generalized and considerable, transudate may accumulate in the body's cavities: in the abdomen (ascites), pleural cavity (hydrothorax) and in the pericardium (hydropericardium). Examination reveals swollen glossy skin.

 

Note divit left (pitting) after application of pressure.
Edema in this case is due to lymphatic obstruction.

 

 

The specific relief features of the oedema-affected parts of the body disappear due to the levelling of all irregularities on the body surface. Stretched and tense skin appears transparent in oedema, and is especially apparent on loose subcutaneous tissues (the eyelids, the scrotum, etc.). In addition to observation, oedema can also be revealed by palpation. When pressed by the finger, the oedematous skin overlying bones (external surface of the leg, malleolus, loin, etc.) remains depressed for 1-2 minutes after the pressure is released. The mechanism of the development of oedema and methods to reveal this condition will be discussed in detail in the special section of this textbook.

 

Allergic edema of lips (Quinke’s edema)

 

Joint deformation in artritis

 

 

The Physical Examination Scheme

·        Appearance

1.    Recognize the severity of patient’s condition, posture, bearing and gate.

·        Vital signs

1.    Measure heart rate, respiratory rate, blood pressure and temperature in an infant and child, demonstrating knowledge of the appropriate sized blood pressure cuff, interval to count respirations, and temperature

2.    Understand that normal values of the heart rate, the respiratory rate and the blood pressure change with age.

3.    Recognize the importance of assessing vital signs in the evaluation of acute illness.

·        Measurements

1.    Accurately measure height, weight and head circumference.

2.    Understand the normal relationships between height, weight and head circumference.

4.    Recognize the usefulness of longitudinal data.

·        Head

1.    Recognize the need for careful observation of the head size and shape, symmetry, facial features, ear size and hair whorls.

2.    Recognize the red reflex and strabismus.

3.    Assess hydration of the mucous membranes. 

·        Neck

1.    Palpate the lymph nodes, know what anatomic areas they drain;

2.    Recognize and demonstrate maneuvers that test for nuchal rigidity.

·        Chest

1.     The rate and pattern of respirations.

2.    Observe the rate and effort of breathing as a measure of respiratory distress.

3.    Recognize stridor, wheezing and rales and be able to distinguish between the inspiratory and expiratory obstruction.

4.    Interpret less serious respiratory sounds such as transmitted upper airway sounds.

·        Cardiovascular

1.    Palpate pulses in the upper and lower extremities and auscultate the heart for rhythm, rate, quality of the heart sounds and murmurs.

·        Abdomen

1.   The liver edge, spleen tip and kidneys percussion and palpation.

2.    Examine the umbilical cord for signs of infection.

3.    Examine the abdomen for distention, tenderness, rebound and mass lesions.

4.    Be able to do a rectal examination and recognize when it is indicated.

·        Extremities

1.    Examine the limbs.

2.    Recognize arthritis. 

·        Back

1.    Know how to test for scoliosis.

·        Skin

1.    Recognize jaundice, petechiae, purpura, common birth marks (such as nevus flammeus and Mongolian spots), vesicles, urticaria and common rashes, such as erythema toxicum, impetigo, eczema, diaper dermatitis and viral exanthems.

2.    Recognize common skin findings associated with child abuse.

3.    Assess skin turgor.

 

Inspection

The method of observation is used during physical examinations. Inspection, or "looking at the patient," is the first step in examining a patient or a body part.