INDEX

GENERAL EXAMINATION........................................................................................................................... 2
Examine the face .......................................................................................................................................... 2
Examine the eyes.......................................................................................................................................... 2
Examine the neck ......................................................................................................................................... 2
EXAMINE THE CARDIOVASCULAR SYSTEM ........................................................................................... 2
EXAMINE THE RESPIRATORY SYSTEM.................................................................................................... 3
EXAMINE THE ABDOMEN........................................................................................................................... 3
EXAMINE THE NERVOUS SYSTEM ............................................................................................................ 3
Higher Cerebral Functions............................................................................................................................ 3
Examine Cranial Nerves............................................................................................................................... 4
Examine the Arms Neurologically ................................................................................................................ 4
Examine the Legs Neurologically ................................................................................................................. 4
Examine the Arms or Legs ........................................................................................................................... 4
EXAMPLE OF PATIENT ENCOUNTER NOTES........................................................................................... 5
Complains of ................................................................................................................................................ 5
History of Present Illness (PI) ....................................................................................................................... 5
Past History (PH) .......................................................................................................................................... 5
Family History (FH)...................................................................................................................................... 5
Personal and Social History (SH) .................................................................................................................. 5
Physical Examination ................................................................................................................................... 5
EXAMPLE OF MINIMAL STATEMENTS ..................................................................................................... 5
General......................................................................................................................................................... 5
Cerebrovascular System:............................................................................................................................... 6
Respiratory System: ...................................................................................................................................... 6
Abdominal System: ...................................................................................................................................... 6
Central Nervous System: .............................................................................................................................. 6
Summary of Minimal Statements.................................................................................................................. 6
HISTORY IN DETAIL..................................................................................................................................... 6
1. Identification & Vital Statistics................................................................................................................. 6
2. Chief Complaints (CC) ............................................................................................................................. 7
3. Present Illness (PI).................................................................................................................................... 7
4. Current Activity........................................................................................................................................ 7
5. Current Medication................................................................................................................................... 7
6. Past History (PH) ...................................................................................................................................... 7
7. Social History (SH) ................................................................................................................................... 8
9. Family History (FH).................................................................................................................................. 8
10. SUMMARY............................................................................................................................................ 8
11. WORKING PROBLEM LIST. ................................................................................................................ 8
12. DATE, TIME, NAME & SIGNATURE .................................................................................................. 8
SPECIMEN HISTORY .................................................................................................................................... 8
HISTORY OF PRESENT ILLNESS (or PI) .................................................................................................. 8
Functional Inquiry ........................................................................................................................................ 9
Respiratory System (RS) ........................................................................................................................... 9
Gastrointestinal (GI) ................................................................................................................................. 9
Genitourinary (GU)................................................................................................................................... 9
Nervous System (NS) ................................................................................................................................ 9
Past Medical History (PH) ............................................................................................................................ 9
Family History (FH)...................................................................................................................................... 9
Personal and Social History (SH) .................................................................................................................10
Medication ..................................................................................................................................................10
COMMONLY USED IMAGING TECHNIQUES AND CLINCAL INVESTIGATIONS.................................10
 For USMLE Study Books visit http://www.book-house.com

GENERAL EXAMINATION

Examine the face

• observe skin: Rodent ulcer (of basal cell carcinoma)
• observe upper face: Paget’s disease, balding, myopathy, Bell’s palsy
• observe eyes: Jaundice, thyrotoxicosis, myxedema, xanthelesma, ptosis, eye palsies, Horner’s syndrome
• observe lower face: Steroid therapy and Cushing syndrome likewise, acromegaly, Parkinson’s disease,
hemiparesis, parotid tumor, thyroid enlargement

Examine the eyes

• observe: Jaundice, anemia, arcus, ptosis, Horner’s syndrome
• examine:
• check if patient is blind - beware of glass eye
• movements of the eyes - amblyopia, palsy, diplopia, nystagmus . . .
• visual acuity
• visual fields
• pupils: light and accommodation reflexes
• fundi: disc, arteries and veins, retina, fovea

Examine the neck

• inspect from front and side

• thyroid (ask patient to swallow - provide a glass of water if necessary)

• lymph nodes
• raised jugular venous pressure
• lymph glands
• other swellings

• inspect from front

• examine neck veins

• feel carotid arteries
• auscultate bruits over thyroid and carotid arteries
• check trachea is central

EXAMINE THE CARDIOVASCULAR SYSTEM

• hands: splinter hemorrhages (seen in endocarditis or more frequently in people doing manual work like
carpenters.)
• radial pulse: rate, rhythm, waveform, volume, state of artery
• Measure blood pressure, but before you begin, ask “I would normally measure the blood pressure now,
would you like me to do so?” This is supposed to make the patient feel a little more comfortable and avoid
the famous “white coat effect.”
• eyes: anemia
• tongue: a blue-purple tongue may indicate central cyanosis, whereas a dry mouth with a dry tongue can be
seen in dehydration and mouth-breathing.
• JVP: height, waveform
• apex beat: site of apex beat, and it’s character
• auscultate:
• at apex (keep thumb on carotid artery for timing)
• normal heart sounds (S1 and S2)
• added sounds (S3 and S4)
• murmurs

2
 For USMLE Study Books visit http://www.book-house.com

• in neck over carotid artery

• each area of precordium with diaphragm
• aortic incompetence: lean patient forward and auscultate with diaphragm
• mitral stenosis: lie patient on left side and auscultate at apex with bell
• “I would normally now listen to the bases for crepitations, examine for hepatomegaly, peripheral edema
and peripheral pulses. Would you like me to do so?”

EXAMINE THE RESPIRATORY SYSTEM

• hands: clubbing, signs of increased carbon dioxide (warm hands, bounding pulse, coarse tremor)
• tongue: central cyanosis
• trachea
• supraclavicular nodes
• inspection
• shape of chest
• chest movements
• respiratory rate / distress?
• palpitation: check for equal (or unequal) movement of chest using hands
• percussion: upper segments, middle segments, lower segments
• auscultation:
• breath sounds
• added sounds: crepitations, bronchospasm, pleural rub, stridor, (vocal fremitus)
• if obstructive airway disease:
• expiration time (In the absence of obstructive airway disease, one should be able to blow out the fire
of a match from approximately 15 centimeters with the mouth open. You can use this as a bedside
test.)

EXAMINE THE ABDOMEN

• hands: clubbing, liver flap (hepatic pre-coma?) , Dupuytren contracture

• eyes: jaundice, anemia
• tongue: fetor is the smell of gastric failure, smooth tongue,
• neck: Virchow’s lypmh node (An abdominal neoplasm – especially gastric ca – may spread to left
supraclavicular lymph node.)
• chest: spider nevi, gynecomastia are signs of liver failure.
• palpate inguinal lymph nodes briefly when you begin examining the abdomen.
• inspect abdomen asymmetry, movement, pulsation, swelling
• inquire whether pain or tenderness
• palpate four quadrants for masses: note abdominal tenderness, guarding, rigidity
• palpate liver, kidneys, spleen, and for aortic aneurysm
• ascites: test for shifting dullness
• auscultate bowel sounds, arterial or liver bruits
• examine for hernia: ask patient to cough. Stand patient up if a hernia is a possibility
• If appropriate: rectal / vaginal examination

EXAMINE THE NERVOUS SYSTEM

Higher Cerebral Functions

• general appearance
• consciousness level
• mood
• speech
• cognitive
• confusion
• orientation

3
 For USMLE Study Books visit http://www.book-house.com

• attention / calculation
• memory – short term, long term
• reasoning – understanding of proverb

Examine Cranial Nerves

CN I smell
CN II visual acuity, visual fields, fundi
CN III, IV, VI ptosis, nystagmus, eye movements, pupils
CN V sensory face, corneal reflex, jaw muscles / jerk, tongue – taste
CN VII face muscles, upper / lower ?
CN VIII hearing, Rinne / Weber tests, nystagmus / gait
CN IX, X palate, swallowing
CN XI trapezius
CN XII tongue wasting, gait

Examine the Arms Neurologically

• inspect:
• abnormal position
• wasting
• fasciculation
• tremor / athetosis
• ask patient to extend arms in front, keep them there with eyes closed, then check
• posture / drift
• tap back of wrists to assess whether position is stable
• fast finger movements (pyramidal)
• touch nose - finger - nose (coordination)
• “Hold my fingers. Pull me up. Push me away”
• tone
• muscle power – each group if indicated
• reflexes
• sensation
• light touch
• pinprick
• vibration
• proprioception

Examine the Legs Neurologically

• inspect:
• abnormal position
• wasting
• fasciculation
• “Lift one leg off the bed, lift other leg off the bed”
• coordination: heel-toe walk
• tone
• power: “Pull up toes. Push down toes.”
• reflexes
• plantar reflexes
• sensation (as hands)
• gait

Examine the Arms or Legs

• inspect:
• color
• skin / nail changes

4
 For USMLE Study Books visit http://www.book-house.com

• ulcers
• wasting (are both arms and legs involved?)
• joints
• palpate:
• temperature, pulses
• lumps
• joints
• active movements
• feel for crepitations
• passive movements
• reflexes
• sensation

EXAMPLE OF PATIENT ENCOUNTER NOTES

Patients Name, Age, Occupation, Date of Admission

Complains of
• list, in patient’s words

History of Present Illness (PI)

• detailed description of each symptom (even if it appears irrelevant!)
• begin from when the patient last felt well
• use chronological order, note with both actual date of onset and time previous to admission,
• If you include history from informant, state this so
• then detail other questions which seem relevant to possible differential diagnoses
• then go through the functional inquiry (‘check’ system for other symptoms)
• write down minimal statement in notes – weight, appetite, digestion, bowels, micturition,
menstruation, if appropriate.

Past History (PH)

• use chronological order

Family History (FH)

• Parents and sibling. Their ages and health. If deceased, of which cause?

Personal and Social History (SH)

• must include details of home circumstances, dependants, patient’s occupation
• effect of illness on life ant its relevance to foreseeable discharge of patient
• smoking, alcohol, drug misuse, medications

Physical Examination
• general appearance, etc.
• then record findings according to systems

EXAMPLE OF MINIMAL STATEMENTS

General
Healthy, well-nourished woman.
Afebrile, not anemic, icteric or cyanosed.
No enlargement of lymph nodes.

5
 For USMLE Study Books visit http://www.book-house.com

No clubbing.
Breasts and thyroid normal.

Cerebrovascular System:
Blood pressure, pulse rate and rhythm.
JVP not raised.
Apex position.
Heart sounds 1 and 2, no murmurs or additional sounds.

Respiratory System:
Chest and movements normal.
Percussion note normal.
Breath sounds vesicular.
No other sounds.

Abdominal System:
Tongue and fauces normal.
Abdomen normal, no tenderness.
Liver, spleen, kidneys, bladder impalpable.
No masses felt.
Hernial orifices normal.
Rectal examination normal.
Vaginal examination not performed.
Testes normal.

Central Nervous System:

Alert and intelligent.
Pupils equal, regular, react equally to light and accomodation.
Fundi normal.
Normal eye movements.
Other cranial nerves normal.
Limbs normal.
Knee jerks + +
Ankle jerks + +
Plantar reflexes ↓ ↓
Touch and vibration normal.
Spine and joints normal.
Gait normal

Pulses (Carotid, Brachial, Radial, Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis) palpable.

Summary of Minimal Statements

Write a few sentences only:

• salient positive features of history and examination

• relevant negative information
• home circumstances
• patient’s medical state
◊ understanding of illness
◊ specific concerns

HISTORY IN DETAIL

1. Identification & Vital Statistics

6
 For USMLE Study Books visit http://www.book-house.com

• Name (Full)
• Sex
• Residence (Complete address)
• Birthdate & Age
• Place of birth
• Nationality & Race
• Marriage Status : Single, Married, Divorced or Widowed
• Occupation
• Informant : Patient or other (Explain relationship)

2. Chief Complaints (CC)

• Each complaint on a separate line, followed by the approximate duration in time units
• As words or phrases and not as complete sentences
• In patient’s or informant’s own words

3. Present Illness (PI)

• This section is the heart of history and should ideally be brief
• Complete sentences in good English
• Always begin from when the patient last felt well. Ask “When did you last feel well?”
• Describe symptom(s) accurately
• Ask about concomitant symptoms
• Ask “Tell me about your problem,” “Give me your story?” Listen without interruption for about
two minutes and begin interjecting questions
• Question the nature of symptoms

• CLARIFICATION : Question until you have sufficient details to categorize the symptom
in medical terms.

• QUANTIFICATION : One big exception is pain which can’t be measured. Try to asses
severity of pain by learning how it affects the patient.

∗ Dyspnea: Amount of exertion?

∗ Hemoptysis: Amount of blood lost?
∗ Alcoholism: Amount of alcohol consumed in a given time period?
∗ Smoking: Number of cigarettes smoked in a given time period?

• CHRONOLOGY: Duration of symptom and it’s appearance time should be noted.

4. Current Activity
• How the disease has diminished the patient’s quality of life and if therapy has improved it

5. Current Medication
• All drugs, doses, effects, and etc.
• If available, prescription bottles may help

6. Past History (PH)

a) GENERAL HEALTH

• BODY WEIGHT (Present, minimum, maximum and dates of each.)

• PREVIOUS PHYSICAL EXAMINATIONS (Dates and findings.)

b) INFECTIOUS DISEASES

7
 For USMLE Study Books visit http://www.book-house.com

• Measles, German Measles, Mumps, Whooping Cough, Chickenpox, Smallpox,

Diphtheria, Typhoid Fever, Malaria, Hepatitis, Scarlet Fever, Rheumatic Fever, Chorea,
Influenza, Pneumonia, Pleurisy, Tuberculosis, Bronchitis, Tonsillitis, Venereal Diseases
and so forth.
• Treatment for infectious diseases?

c) OPERATIONS AND INJURIES

• Dates and nature of all operations and injuries

d) PREVIOUS HOSPITILIZATION

• Why, when and where?

e) REVIEW OF SYSTEMS / FUNCTIONAL INQUIRY

Skin Lymph Nodes

Bones, Joints & Muscles Hematopoietic System
Endocrine System Allergic & Immunologic History
Head Eyes
Ears Nose
Mouth Throat
Neck Breasts
Respiratory System Cardiovascular System
Gastrointestinal System Genitourinary System
Nervous System Psychiatric History

7. Social History (SH)

• Birthplace and places of residence
• Marital Status / Causes for termination
• Gender Preference
• Habits
• Social and Economic Status
• Advance Directives

9. Family History (FH)

• PARENTS & SIBLINGS: Age & Health / Age at death & causes?

10. SUMMARY.

11. WORKING PROBLEM LIST.

12. DATE, TIME, NAME & SIGNATURE

SPECIMEN HISTORY

Mr. John Smith

Aged 52. Machine operator. Oxford.

C/O severe chest pain for 2 hours. (C/O for Complains Of, or CC for Current Complaint)

HISTORY OF PRESENT ILLNESS (or PI)

8
 For USMLE Study Books visit http://www.book-house.com

The patient was perfectly well until 6 months ago. He then began to notice central, dull chest ache,
occasionally felt in the jaw, coming on when walking about 1 km (1/2 mile), worse when going uphill and
worse in cold weather. When he stopped, the pain went off after 2 minutes. The patient found that glyceryl
trinitrate spray relieved the pain rapidly. In the last month the pain came on with less exercise after 100 yards.

Today at 10 a.m. while sitting at work the chest pain came on without provocation. It was the worst
pain he had ever experienced in his life and he thought he was going to die. The pain was central, crushing in
nature, radiating to the left arm and neck and with it a feeling of nausea and sweating. The patient was rushed
to hospital where he received an intravenous injection of diamorphine, which rapidly relieved the pain, and
intravenous streptokinase. An electrocardiogram confirmed a myocardial infarction and the patient was
admitted to coronary care unit.

The patient has noticed very mild breathlessness on exertion for 3 months, but had not experienced
palpitations, dizziness, breathlessness on lying flat, ankle swelling or coughing. On one occasion, however, 2
weeks ago the patient had woken with a suffocating feeling and had had to sit on the edge of bed and
subsequently open the window to get his breath. This had not recurred and he did not report it to his doctor.

Functional Inquiry

Respiratory System (RS)

• morning cough over the last 3-4 winters with production of a small amount of clear sputum
• no hemoptysis

Gastrointestinal (GI)
• occasional mild indigestion
• bowels regular
• appetite normal
• no other abnormalities

Genitourinary (GU)
• no difficulties with micturition
• normal sex life

Nervous System (NS)

• infrequent frontal headaches at the end of a hectic day
• otherwise no abnormalities
• no psychiatric symptoms

Past Medical History (PH)

Fifteen years ago appendectomy. No complications.
No other operations or serious illness.
No history of rheumatic fever, nephritis or hypertension.
Never been abroad.

Family History (FH)

Father died aged 73 – ‘heart attack’
Mother died aged 71 – ‘cancer’
Two brothers fit and well (aged 48 and 46).
Two sons (aged 23, 25), both fit and well.
No family history of diabetes or hypertension.

9
 For USMLE Study Books visit http://www.book-house.com

Personal and Social History (SH)

Happy both at work and home. Both sons married and living in Oxford.
Wife works as an office cleaner. No financial difficulties.
Smokes 20 cigarettes a day. Two pints of beer on Saturdays only.
Patient always worked as a machine operator since leaving school except for two years in Hong Kong, where he
had no illness.

Medication
Other than glyceryl trinitrate spray, no drugs currently being taken.

COMMONLY USED IMAGING TECHNIQUES AND CLINCAL INVESTIGATIONS

• Ultrasound Examination
• Liver, gallbladder, pancreas, kidneys, spleen, ovaries, uterus, aorta, bowel, pleura, blood vessel
aneurysms & stenoses, thyroid, scrotum, joints, soft-tissue masses . . .
• Endoscopy
• Gastroscopy, Proctoscopy, Sigmoidoscopy, Colonoscopy, Bronchoscopy, Laparoscopy, Cystoscopy,
Colposcopy
• Needle Biopsy
• Core Biopsy (Liver, Kidney, Lung)
• Fine-needle Aspiration (Tumors / Bacteriological investigations)
• Radiography
• Chest Radiograph “PA Chest Radiograph”
• Abdominal Radiograph “Supine AP Radiograph” and “Erect Abdominal Radiograph”
• Computerized Tomography
• Organs & Masses in abdomen and thorax, tumors-infarcts-bleeds in brain, posterior fossa lesions,
disc prolapse and neoplasm in spinal cord
• Arteriography and Venography
• Coronary, cerebral, carotid, pulmonary, renal, aortography and ilofemoral angiography, leg
venogram
• Background Subtraction Angiography
• Nuclear Medicine Studies (Technetium 99m Scan - Scintigraphy)
• Skeletal, pulmonary, cardiovascular (myocardial perfusion scintigraphy), urogenital, cerebral,
thyroid, adrenal, reticuloendothelial system
• MRI
• Excellent in brain
• Electrocardiography
• Exercise Electrocardiography
• Echocardiography
• Radionuclide Ventriculography (Multiple Gated Acquisition – MUGA Scan)
• Assesses ventricle function
• Pyrophosphate Scanning
• Demonstrates recent myocardial infarction (1-10 days)
• Doppler Ultrasound Cardiography
• Multigated Doppler / Color-flow Doppler
• Cardiac Catheterization
• 24 Hour ECG Tape Recording (Holter)
• 24 Hour Blood Pressure Recording
• pH and Blood Gases
• Peak Flow
• Spirometry
• Skin Testing for Allergens
• Ventilation / Perfusion Scan
• Endoscopic Retrograde Cholangiopancreaticography
• Visualizes the biliary tree and pancreatic ducts

10
 For USMLE Study Books visit http://www.book-house.com

• Barium Swallow, Meal, Enema

• Hydrogen Breath Tests
• Lactulose Breath Test: Bacterial overgrowth
• Lactose Breath Test: Lactase deficiency
• Urine Analysis
• Urine Microscopy
• Creatinine Clearance (GFR)
• Intravenous Urogram
• Electroencephalogram
• Lumbar Puncture
• Myelogram
• Cervical disk prolapses or cord tumors
• Lumbar Radiculogram
• Lumbar disk prolapses

11