The history and general principles governing the physical examination

CLINICAL EXAMINATION
1)

History of the patient disability

a)
b)

2)

a general clinical history

a detailed clinical history

Physical examination
a)
b)

general assessment
systemic examination

A GENERAL CLINICAL HISTORY

1)
2)
3)

The approach to the patient

The patients account of the current illness
Interrogation (interview)

INTERROGATION (INTERVIEW) BY THE DOCTOR

1)

The current illness

a)
b)
c)

2)
3)
4)
5)
6)

major complaints
systemic enquiry
information from a third party

Previous illness and state of health

Drug history
Family history
Social history
The psychological assessment

THE CURRENT ILLNESS

Major complaints
1)
2)

please, tell me about your present trouble..., what brings you here?...
when did your trouble start ?...
what was the first thing you felt wrong?...
what happened next ?...
can you show me where you get the pain ?...
what colour is it ?...
how often ?...

Systemic enquiry: standard questions

1)

Cardiovascular system:
ankle swelling, palpitations, breathlessness when lying flat (orthopnoea), attacks of nocturnal
breathlessness (paroxysmal nocturnal dyspnoea) chest pain on exertion, pain in legs on exertion

2)

Respiratory system:
shortness of breath: exercise tolerance, wheezing, cough, sputum production (colour, amount), chest
pain isolated to respiration or coughing, blood in sputum (haemoptysis)

3)

Central nervous system:

headaches, visual symptoms (e.g. double vision, lost of acuity or visual fields), fits, faints, tingling
(paresthesiae), numbness, muscle weakness, hearing symptoms (e.g. deafness, tinnitus), excessive
thirst, sleep patterns.
4)

Urogenital:
pain on passing urine (dysuria), frequency of passing urine (nocturia), abnormal colour of urine (e.g.
blood), number of sexual partners,
males: if appropriate age ask for prostatic symptoms such as difficulty in starting to pass urine, poor
stream, terminal dribbling, if appropriate ask for mental attitude to sex (libido), morning erections,
frequency of intercourse, ability to maintain erections, ejaculation, urethral discharge
female: if premenopausal, age of onset periods (menarche), regularity of periods (e.g. 28- days cycle),
length of period, blood loss (e.g. clots, flooding), note of last period, contraception if relevant, presence
of vaginal discharge, stress and/ or urge incontinence, pain during intercourse (dyspareunia), postmenopausal bleeding where relevant

5) Alimentary:
condition of mouth (infected tongue or bleeding gums), difficulty with swallowing (dysphagia),
indigestion, heartburn, abdominal pain, weight loss, change in bowel habits, colour of motion (e.g. pale,
dark, tarry black, fresh blood)
6) Locomotor:
joint pain or stiffness, muscle pain or weakness
7) Endocrine:
heat intolerance, cold intolerance, change in sweating, prominence of eyes, swelling in neck
Information from the third party

relative or friend
eye witness
a search of patients clothing and personal belongings
GP
a hospital staff (students, nurses, social workers...etc.)

PREVIOUS ILLNESS AND STATE OF HEALTH

1)
2)
3)

information about illnesses, operations, accidents (ask for previous medical records)
residence or travel abroad
previous health: medical examination for insurance, record the blood pressure, previous radiological
examination

DRUG HISTORY
1)

Information about drugs that have been taken previously

2)
3)
4)

it may provide a diagnosis

warn about drug interaction and adverse effects
indicate how effective or ineffective previous treatments have been

What medicines the patients is currently taking

Previous adverse experience
Information regarding drugs of addiction

Medicines should be identified !

FAMILY HISTORY
1)
2)

Information regarding the age and health or cause of death of patients` relatives: parents, siblings
Information about more intimate matters: alcoholism, emotional disturbances

SOCIAL HISTORY
1)
2)
3)
4)
5)

A description how the patient spend the average day

The home (co-operation with the social worker)
Occupation
Personal interest (physical exercise, intellectual activities)
Habits (tobacco, alcohol, food)

PHYSICAL EXAMINATION
1)
2)

3)

General assessment
Cardiovascular examination
Respiratory examination
Abdominal examination
Neurological examination
Locomotor examination
Laboratory tests and image techniques

General assessment

Demeanour and general condition.

Posture and gait
Physique and nutritional status
State of hydration and presence of oedema
Height and weight
Finger clubbing
Head, face and neck (goiter...)
Skin and subcutaneous tissues
Breasts
Lymphadenopathy

Cardiovascular system
1)
2)
3)
4)

Arterial pulse and pressure

Jugular venous pulse and pressure
Heart: inspection, palpation, auscultation
Peripheral circulation: arterial, venous

Respiratory system
1)
2)
3)

Examination of sputum
Upper respiratory tract (nose, tonsils, pharynx)
Chest: inspection, palpation, auscultation

Abdominal examination
1)
2)
3)
4)
5)
6)
7)
8)

Inspection (distension, movement, shape)

Palpation
Percussion
Auscultation
Digital examination
Examination of stool
Urine
Genitalia: inspection, palpation (in special circumstances only)

Nervous system
1)
2)
3)
4)
5)
6)
7)

Mental state
Speech and language
Cranial nerves
Motor system
Sensory system
Reflexes
Supplementary tests

Locomotor system

1)
2)
3)
4)

Spine
Joints and limbs
Muscles
Bones

Examination of the mental state

1)
2)
3)
4)
5)

General appearance and behaviour

Thought processes
Mood
Delusions, hallucinations, obsessions
Intellectual functions:
orientation
memory
attention and concentration
general information
intelligence

Inherited diseases with important cardiac components:

familial hypercholesterolaemia, homocistinuria, Downs syndrome, Turner`s syndrome, Noonan`s
syndrome, Marfan`s syndrome, Ehlers- Danlos syndrome, Friedreich`s ataxia, dystrofia myotonica,
neurofibromatosis
Cardiac components of multisystem diseases:
diabetes mellitus, alcoholism, polyarteritis nodosa, systemic lupus erythematosus, rheumatoidarthritis
or sarcoidosis
Drug and heart disease:
hypertension (corticosteroids, ephedrine...)
fluid retention (corticosteroids, liquorice...)
sinus tachycardia (Salbutamol, Thyroxine...)
tachyarrythmias (digoxin, diuretics...)
bradyarrythmias (beta- blockers, Verapamil...)
History of cardiovascular system
1)

2)

Symptoms of heart disease

a)
dyspnoea
b)
pain
c)
oedema
d)
other symptoms of heart disease
Symptoms of peripheral vascular disease
a)
arterial insufficiency
b)
venous insufficiency

Symptoms of peripheral vascular disease

1)

Arterial insufficiency
pain in the limb, loss of function, altered cutaneous sensation, cold (the acute form, chronic arterial
insufficiency, severe chronic arterial insufficiency)

2)

Venous insufficiency
pain of the limb, warmth, swelling, tenderness (the acute form, chronic venous insufficiency)

Symptoms of heart disease

1)

2)

Dyspnoea
a)
b)
c)

dyspnoea on effort: first symptom of left heart failure

paroxysmal nocturnal dyspnoea: characteristic symptom of left heart failure
orthopnoea: breathlessness demanding the upright position

Oedema
a)

impairment of renal blood flow

b)
c)
d)
e)
f)
3)

Pain
a)
b)
c)

4)

increased venous pressure

the effect of aldosterone
antidiuretic hormone
lymphatic factors
oncotic pressures

the analysis of a pain: main site, radiation, character, severity, duration, frequency and
periodicity, special times of occurrence, aggravating factors, relieving factors, associated
phenomena
angina pectoris: chest pain- the principal symptom of myocardial ischemia
other chest pains of cardiovascular origin

paroxysmal tachycardia

pericarditis

pericardial effusion

dissecting aneurysm

mitral prolapse

pericardial catch

Other symptoms of heart disease

palpitation
cough
haemoptysis
syncope
tiredness
eyes
gastrointestinal symptoms
renal function

Symptoms of disease of the upper respiratory tract

1)
2)
3)

Nose and nasopharynx: nasal obstruction, nasal discharge, epistaxis

Larynx: hoarseness, cough, laryngeal stridor, laryngeal pain
Trachea: tracheal pain, tracheal stridor

History of previous illness

Tuberculosis, pneumonia and pleurisy, other respiratory illness, chest injuries and operations, other surgical
procedures, acute abdominal conditions, allergic disorders, previous radiological examinations
HISTORY OF RESPIRATORY SYSTEM
1)
2)
3)
4)
5)

Symptoms of respiratory disease

cough, sputum, haemoptysis, chest pain, breathlessness (dyspnoea), apnoea, wheeze
Symptoms of disease of the upper respiratory tract
Nose and naso- pharynx, larynx, trachea
History of previous illness
Family and social history
Occupational and other environmental hazards

Symptoms of respiratory disease

1)

Cough:
-frequency, severity, character (harsh, dry, paroxysmal, loose and readily productive
of sputum, short and half- suppressed by pain...)
-is dependent on: the situation and nature of lesion responsible for the cough, the
presence or absence of sputum, coexisting abnormalities (e.g. vocal cord paralysis,
impairment of ventilatory function, pleural pain)

2)
3)
4)

Sputum: amount, character (serous, mucoid, mucopurulent, purulent, rusty), vicosity, taste or odour
Haemoptysis: frequency and d duration
Chest pain:
(due to respiratory disease)
upper retrosternal pain (acute tracheitis)
retrosternal pain associated with lesions of the mediastinum

5)

6)

7)
8)

pleural pain
Breathlessness (dyspnoea) associates with:
an increase in the work of breathing
increased pulmonary ventilation
weakness of the muscles of respiration
multiple factors (pneumonia, pulmonary oedema)
a)
acute onset breathlessness (bronchial asthma, massive pulmonary embolism...)
b)
exertional breathlessness
Apnoea
breath may be voluntarily held for short periods
periods of apnoea alternate with overventilation (Cheyne- Stoke breathing)
during sleep (obstructive, central)
Wheeze
obstruction of the small airways
Stridor
obstruction of the large airways

Family and social history

1)
2)
3)
4)

Infections (tbc...)
Allergic disorders
Chronic bronchitis
Social problems (housing, finance, employment...)
Cigarette smoking
Obesity

Occupational and other environmental hazards

The inhalation of certain inorganic and organic dusts and chemical substances
Points of special emphasis
1)A detailed clinical history is usually more helpful in making the correct diagnosis than is
the physical examination
2)The essential skill in history- taking is the ability to listen to the patients story. This
requires establishing a good report
3)Any system of history- taking must be flexible and also methodical
4)The history of the presenting complaint includes events right up to the time of the interview
5)The personal history should include details of tobacco and alcohol consumption, travel
abroad, current medication and allergy
6)The clinician must be prepared to listen to, and as necessary discuss, personal problems
without embarrassment