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2 History and examination
Fig 2.
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23
Physical signs on respiratory examination.
Table 2.
8
Auscultation
Breath sounds Description Pathology
Vesicular Soft, low- pitched blowing/ rustling Normal
Bronchial
breathing
Reduced breath
sounds
Silent Inaudible breath sounds Life- threatening asthma
Wheeze
(rhonchi)
Crepitations Crackles: small airways reopen in
Pleural rub Creak like foot in snow. Due to
Pneumothorax
click
Harsh. Expiration and inspiration of
equal volume and length with a gap
between inspiration and expiration
Quiet, dicult to hear Pleural eusion/ thickening,
• Monophonic: single note, partial
obstruction of one airway
• Polyphonic: multiple notes, wide-
spread airway narrowing
inspiration:
• Fine and late in inspiration • Pulmonary oedema
• Coarse and mid inspiratory • Bronchiectasis
• Early inspiratory • Small airway disease
• Late/ pan inspiratory • Alveolar disease
movement of visceral over parietal
pleura when both are inflamed
Click during cardiac systole Shallow left pneumothorax
Consolidation, localized fibrosis,
above pleural/ percardial eusion
(Ewart’s sign,
pneumothorax, occlusion
• Airway occlusion: tumour,
• Asthma, ‘cardiac’ wheeze
Pneumonia, pulmonary
infarction
overlying heart
p
132
)
foreign body
from pulmonary oedema
51
2 History and examination
The gastrointestinal system: history
NSAID
IBS
IBD
ICP
SOCRATES
NSAID
NSAID
LMP
CNS
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52
Gastrointestinal symptoms are detailed in table
Table 2.
9
Presenting symptoms and questions to ask
Presenting symptom Questions
Abdominal pain (p53, p
Nausea, vomiting (
Haematemesis (
Dysphagia (
Indigestion/ dyspepsia/ reflux (
Change in bowel habit: diarrhoea
p
254
), constipation (p
(
Rectal bleeding (
p
252
)
(
Appetite, weight change
Distension (p54) Timing? Alcohol use? Pain? Itch? Jaundice?
Jaundice (
table 2.10)
pp
252–3
p
246
)
p
621
p
268
)
Past hi story Peptic ulcer disease, cancer, jaundice, hepatitis, blood transfusion,
tattoos, surgery, last menstrual period, dietary changes, surgery/ dialysis abroad.
Drug history Especially steroids,
Fam i ly h is to ry Irritable bowel syndrome (
polyps, cancer, jaundice.
Social history Smoking, alcohol (quantify units/ week), recreational drug use, travel
history, contact with jaundiced persons, occupational exposure, sexual history.
Vom iti ng History is vital. Associated symptoms and medical history may indicate
table
2.10
cause (
). Examine for dehydration, distension, tenderness, mass, succussion
splash in children (pyloric stenosis), tinkling bowel sounds (intestinal obstruction).
Table 2.
10
Causes of vomiting
Gastrointestinal
• Gastroenteritis
• Peptic ulceration
• Pyloric stenosis
• Intestinal obstruction
• Paralytic ileus
• Acute cholecystitis
• Acute pancreatitis
Alcohol and drugs Psychiatric Other
• Antibiotics
• Opioids
• Cytotoxics
Non- gastrointestinal causes of vomiting? Try ABCDEFGHI:
Addison’s disease. Foreign substances (alcohol, drugs).
Brain (eg i
). Gravidity (hyperemesis).
Cardiac (myocardial infarct). Hypercalcaemia/ Hyponatraemia.
Diabetic ketoacidosis. Infection.
Ears (labyrinthitis, Ménière’s disease).
598
)
)
p
248
) Timing (relation to meals)?
256
)
), melaena
• Meningitis/ encephalitis
• Migraine
• iIntracranial pressure
• Brainstem lesion
• Motion sickness
• Ménière’s disease
• Labyrinthitis
• Psychogenic
• Bulimia nervosa
2.9
(p26)
Timing? Relation to meals? Amount? Content: liquid, solid, bile, blood? Frequency?
Fresh (bright red)? Dark or ‘coee grounds’?
Consider cancer: weight loss, dysphagia, pain,
melaena? Medications:
Level? Onset? Intermittent? Progressive? Painful
swallow (odynophagia)?
Symptoms of malignancy: weight loss, anaemia,
melaena? Pale stools/ steatorrhoea (p55)? Pain
on defecation? Mucus? Polyuria/ kidney stones
2
+
). Antibiotics? Thyroid symptoms (p29)
(iCa
Fresh/ dark/ black? Pain on defecation? Perianal
pain? Mucus? Mixed with stool/ on surface/ on
paper/ in the pan?
Quantify. Intentional? Dysphagia? Pain? See
Pruritus? Dark urine? Pale stools?
S, antibiotics, anticoagulants.
S, anticoagulants?
S?
), inflammatory bowel disease (
Metabolic/ endocrine
Uraemia
Hypercalcaemia
Hyponatraemia
Pregnancy
Diabetic ketoacidosis
Addison’s disease
• Myocardial infarction
• Autonomic neuropathy
• Sepsis
p
35
?
),
2 History and examination
Abdominal pain Occurs due to a number of possible pathological mechanisms: ir-
UTI
UTI
OHCS
OHCS
https://t.me/med1917
ritation of the mucosa (acute gastritis), smooth muscle spasm (enterocolitis), capsular stretch (liver lesion/ bleed), peritoneal inflammation (acute appendicitis),
direct splanchnic nerve stimulation (retroperitoneal extension of tumour).
Character Constant or colicky, sharp or dull?
Duration and frequency Depend on the mechanism of production. Colic is an inter-
mittent pain with sudden onset and cessation. It is due to the contraction of muscles around a partial or complete blockage in a luminal organ: small intestine, large
intestine, rectum, gallbladder, ureter.
Location and distribution May help determine aetiology:
• Epigastric: gastritis/ duodenitis, peptic ulcer, gallbladder disease, pancreatitis,
aortic aneurysm.
• Left upper q uadrant: peptic ulcer, gastric or colonic (splenic flexure) disease,
splenic rupture, subphrenic abscess, renal colic, pyelonephritis.
• Right upper quadrant: cholecystitis, biliary colic, hepatitis, peptic ulcer, colonic
(hepatic flexure) disease, renal colic, pyelonephritis, subphrenic abscess.
• Loin (lateral ⅓ of back between thorax and pelvis), merges with flank (side be-
tween ribs and pelvis,
from spine.
• Left ili ac fossa: diverticulitis, volvulus, colon cancer, inflammatory bowel disease,
hip pathology, renal colic,
itis, ectopic pregnancy.
• Right iliac fossa: all causes of left iliac fossa pain plus appendicitis and Crohn’s ile-
itis, and usually excluding diverticulitis.
• Pelvic:
p
140
), endometritis (
(
• Generalized: gas troent eriti s, irr itabl e bowel syndro me, pe riton itis, constipation.
• Central: mes enter ic ischaemia , abdominal a neurys m, pan creati tis.
• Referred pain: my ocardi al inf arct, p leural patho logy, hi p dise ase, h erpes zoster.
Time of occurrence Meals, defecation, sleep.
Aggravating/ relieving factors Food, defecation, urinary symptoms, movement.
p
563
): renal colic, pyelonephritis, renal tumour, referred pain
(p
292
), pelvic abscess, ovarian cyst torsion, salping-
, urinary retention, menstruation, ectopic pregnancy, endometriosis
p
136
), salpingitis, ovarian cyst torsion.
53
2 History and examination
The gastrointestinal system: symptoms and signs
MRI
RIF
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54
Abdominal distension
• Resonant: flatus.
• Dull: solid lesion, eg colon, stomach, pancreas, liver, or kidney tumour. Fluid, eg ascites
(shifting dullness) due to malignancy or cirrhosis; distended bladder (cannot get below it).
• Expansile: ane urysm.
• Pelvic: uterin e fibroi ds, ovar ian cys t/ tumour.
ascites with portal hypertension (p
See also
Hepatomegaly and splenomegaly
Hepatomegaly
• Malignancy: prim ary or metas tatic. Us ually c raggy, i rregu lar edg e.
• Congestion: r ight hea rt fa ilu re ( puls ati le h epat ome galy if s ever e tr icu spid reg urgi ta-
tion), hepatic vein thrombosis (Budd– Chiari syndrome,
• Anatomical: Ri edel’s lobe— a normal variant.
• Infection: infectious mononucleosis, viral hepatitis, malaria, schistosomiasis, amoebic
abscess, hydatid cyst.
• Haematological: leukaemia, lymphoma, myeloproliferative disease, sickle cell dis-
ease, haemolytic anaemia.
• Other: fat ty liv er, po rphyri a, amy loido sis, glyco gen st orage d isorde r.
Splenomegaly (p
Myelofibrosis, Malaria, leishManiasis.
Hepatosplenomegaly See p
596
Spleen or enlarged kidney?
• Cannot get above a spleen (ribs overlie the upper border of the spleen).
• Spleen is dull to percussion (kidney usually resonant because of overlying bowel).
• Spleen moves towards
• Spleen may have palpable notch on its medial side.
Faecal incontinence
Aects daily activity in 1– 2% of adults. Continence depends on mental function, stool
volume/ consistency, sphincter function, rectal distensibility, anorectal sensation, and
reflexes. Defects in any can cause incontinence. Distinguish from faecal soiling.
Causes
Consider cord compression if acute faecal incontinence.
• Sphincter dysfunction: sphincter tears or pudendal nerve damage, eg at vaginal
delivery, surgical trauma, fissure.
• Impaired sensation: diabetes, MS, dementia, spinal cord lesions.
• Faecal i mpact ion: ov erflow d iarrh oea is commo n and t reatab le.
• Idiopathic: no clear cause found, may be multifactorial, eg poor sphincter tone plus
pudendal damage.
Assessment
Rectal examination: overflow incontinence? Poor tone?
Neurological examination of legs, particularly checking sensation.
• Consider anorectal manometry, pelvic ultrasound/
Treat according to cause, and to promote dignity
Urgent referral if possible cord compression.
• Find and use specialist continence services. Skin care.
• Ensure toilet is in easy reach. Plan trips in the knowledge of toilet location.
• Obey call- to- stool impulses (especially after meal: the gastro- colic reflex).
• Ensure access to continence aids and individualized advice on their use: an anal cotton
plug may help isolated internal sphincter weakness.
• Pelvic fl oor reh abilit ation can i mprove s queeze pr essure and t olerate d volum e.
• There is li mited evid ence th at drug tr eatme nts inc ludin g antid iarrh oeal ag ents ( lopera -
mide, diphenoxylate plus atropine, codeine) and drugs to enhance anal sphincter function (phenylephrine gel, sodium valproate) work.
596
), other abdominal masses (p
p
686
).
). If Massive, think of the ‘M’s: chronic Myeloid leukaemia,
596
.
wit h insp iratio n (kid ney ten ds to move d ownward s).
, pudendal nerve testing.
596
).
2 History and examination
Dyspepsia
GI
GI
A, D, E, K
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Dyspepsia and indigestion (p
or more of: post- prandial fullness, early satiety, epigastric/ retrosternal pain or
burning. ‘Indigestion’ reported by the patient can refer to dyspepsia, bloating,
nausea, or vomiting. Try to find out exactly what your patient means and when
these symptoms occur in relation to meals, eg classic symptoms of peptic ulcer-
2– 5
hours after a meal. Check for red flag symptoms (p
ation
with dyspepsia undergo endoscopy, <
Myocardial infarction may present as ‘indigestion’.
Regurgitation
Gastric and oesophageal contents are regurgitated eortlessly into the mouth
without contraction of abdominal muscles and diaphragm (so distinguishing it
from true vomiting). It may be worse on lying flat, and can cause cough and nocturnal asthma. Commonly associated with dyspepsia. Consider other causes if associated with nausea. Contributing pathologies: oesophageal pouch, high upper
obstruction.
Flatulence
Normally
400– 1300
per day. If this, with any eructation (belching) or distension, seems excessive to the
patient, they may complain of flatulence. Eructation occurs in hiatus hernia, but
most patients with ‘flatulence’ have no
may be useful: N
bacteria (and reducing carbohydrate intake may help).
Te ne s mu s
A sensation in the rectum of incomplete emptying after defecation. Malignancy
needs exclusion before it can be attributed to irritable bowel syndrome (
Steatorrhoea
Pale stools that are dicult to flush, and are caused by malabsorption of fat in
the small intestine and hence greater fat content in the stool.
(eg Crohn’s, ileal resection), pancreatic disease, obstructive jaundice (dexcretion of
bile salts from the gallbladder).
fat- soluble vitamins (
Halitosis
Halitosis (fetor oris, oral malodour) results from gingivitis (rarely severe enough
to cause Vincent’s angina,
compound- producing bacteria (locally retained bacteria on tongue metabolize
sulfur- containing amino acids to yield volatile ( smelly) hydrogen sulfide and
methyl mercaptan). Patients can be anxious and convinced of halitosis when it is
not present (and vice versa!).
isosorbide), lung disease, dry mouth (so eat/ drink regularly).
giene (floss, tongue scraping), mouthwash (
mouthwash), or products containing metal ions (eg Zn) to inhibit odour via anity
of metal ion to sulfur.
mL of gas is expelled PR in 8– 20 discrete (or indiscrete) episodes
in air swallowing (aerophagy), methane if fermentation by bowel
2
248
) are broad terms. Dyspepsia is defined as one
245
33
% have clinically significant findings.
pathology. Knowledge of the chief gas
Treatment According to cause. May be deficient in
).
p
698
), metabolic activity of bacteria in plaque, or sulfur
Contributory factors Smoking, drugs (disulfiram,
0.2
% aqueous chlorhexidine gluconate
). If all patients
Causes Ileal disease
Treatment Dental hy-
p
264
).
The Famous Five
Enid Blyton’s Famous Five characters can solve any crime or diagnostic
problem using
confection- laden midnight feasts, and lashings of ginger beer. Let us give them
the problem of abdominal distension. The sweets and drinks used by the Famous
Five actually contribute to the causes of abdominal distension:
If you think it is far- fetched to implicate ginger beer in the genesis of fetuses,
note that it was home- made. Like fun, there is no limit to the intoxicating power
of a home- made remedy in a long- ago vintage summer. So do not forget to ask,
‘When was your last period?’ in all those born female.
1950
s methodologies steeped in endless school holidays, copious
Fat Fluid Faeces Flatus Fetus
55
2 History and examination
The genitourinary system: history
BOX
OHCS
UTI
STI
STI
UTI
STI
UTI
OHCS
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56
Symptoms
• Feve r.
• Dysuria (see
289
).
, p
p
• Loin pain.
• Scrotal/ testicular pain: must rule out testicular torsion (p
• Haematuria (p
• Urethral/ vaginal dis charge (p
• Dyspareunia (
Past history Renal colic,
Menstrual history Menarche, last menstrual period, timing of cycle, menopause,
bleeding pattern, additional bleeding (intermenstrual/ postcoital/ postmenopausal).
Sexual history 5Ps: Partners, Practices, Protection from
Drug history Anticholinergics, antibiotics.
Fam i ly hi st o ry Prostate carcinoma? Kidney disease?
Dysuria
Be sure you mean the same as your patient and your colleagues.
Dysuria Typically pain derived from urethra or bladder. Consider
/ urethritis (p
409
look for a urethral caruncle: fleshy outgrowth of distal urethral mucosa,
typically originating from the posterior urethral lip. It may be dicult to distinguish from vaginal pain (consider vaginitis, vulvitis, or vaginal inflammation,
eg from spermicides, perfumed bath products). Rare causes: stones, urethral lesions (eg carcinoma, lymphoma, papilloma), postpartum trauma.
Strangury Urethral pain, usually referred from the bladder base, causing a constant
distressing desire to urinate even if there is little urine to void. Causes: bladder stone,
catheter, cystitis, prostatitis, bladder neoplasia, bladder endometriosis, schistosomiasis.
Voi din g d iculty A sign of obstruction to normal urine outflow. Features include
poor flow, straining to void, hesitancy, intermittent stream, incontinence (overflow),
urinary retention (acute or chronic), incomplete emptying (±
Ask about lower urinary tract symptoms: pain, frequency, urgency, nocturia, obstructive symptoms:
• On trying to pass water, is there delay before you start? (Hesitancy.)
• Do you go on dribbling after you have tried to stop? (Te r mi n a l d r ib b l i ng .)
• Is your stream getting weaker? (Poor stream.)
• Is your stream painful/ slow/ ‘drop- by- drop’? (Eg from bladder stone.)
• Do you feel the bladder is not empty after passing urine?
• Do you ever pass urine when you do not want to? (Incontinence, p
• On feeling the need to pass urine, do you have to go straight away? (Urgency.)
• Do you urinate often during the day? (Freq uenc y.). How often?
• Do you urinate often at night? (Nocturia.).2 How often?
Causes
Obstructive: prostatic hyperplasia, uterine prolapse, retroverted gravid uterus,
fibroids, ovarian cyst, urethral foreign body, ectopic ureterocele, bladder polyp,
bladder cancer, oedema after surgery/ catheter.
Bladder overdistension: eg after epidural.
Detrusor weakness/ myopathy: incomplete emptying + overflow incontinence
secondary to neurological disease, eg suprapontine stroke, cord lesion, multiple
sclerosis, neuropathy (spinal cord compression, diabetic neuropathy).
Drugs: epidural anaesthesia, tricyclics, anticholinergics.
Other: reflex due to pain (eg herpes infection), interstitial cystitis (
Remember faecal impaction as a cause of urinary retention.
2
With advanced age, nocturia (1– 2/ night) may be ‘normal’ because of: i) loss of ability to concentrate
urine; ii) peripheral oedema returns to the circulation at night; iii) circadian rhythm may be lost; iv) less
sleep is needed and waking may be interpreted as a need to void (a conditioned Pavlovian response).
639
).
409
137
).
).
, diabetes, iBP, gout, analgesic use (p
), spermicides, urethral syndrome (p
644
).
314
), surgery.
, Previous
292
). If postmenopausal,
in residual urine).
640
.)
, Pregnancy.
prostatitis,
1
cm,
p
158
).
2 History and examination
Irritative or obstructive bladder symptoms
UTI
UTI
UTI
UTI
PIP
https://t.me/med1917
Symptoms of prostate enlargement are miscalled ‘prostatism’ (thereby excluding
p
634
other pathologies, eg bladder neck obstruction, stricture (
fine irritative or obstructive bladder symptoms:
• Irritative bladder symptoms Urgen cy, dysu ria, f reque ncy, noc turia .
• Obstructive symptoms Reduced s ize and force of urinar y stream, he sitanc y, inter rup-
)). It is better to de-
tion of stream during voiding, terminal dribbling. The most common cause in men is
enlargement of the prostate (prostatic hyperplasia). Also urethral stricture, tumour,
urethral valves, bladder neck contracture.
Polyuria and urinary frequency
Polyuria = iurine volume, eg >3L/ 24h (but consider body mass).
Causes Over- enthusiastic IV fluid therapy, diabetes mellitus & insipidus (diabetes
is Greek for fountain), iCa
2
+
, psychogenic polydipsia/
syndrome (p
234
), polyuric
phase of recovery after acute tubular necrosis, diuretics, alcohol, renal tubular
disease, adrenal insuciency.
Dierentiate polyuria from frequent passage of small amounts of urine (eg cystitis,
urethritis, neurogenic bladder, bladder compression).
Oliguria/ anuria
• Oliguria is defi ned as a ur ine out put of <0.5mL/ kg/ h and can be a sign of reduced circulating volume, acute kidney injury, or advanced chronic kidney disease.
• Anuria is defined as <50mL/ 24h. A catheterized patient with sudden anuria has a
blocked catheter until proven otherwise. Slower progression from oliguria to anuria is
more likely due to kidney disease.
Urinary changes
• Cloudy urine can b e pus (
urine.
• Pneumaturia (bubbles in urine as it is passed) occurs with
) but is often normal phosphate precipitation in an alkaline
due to gas- forming
organisms or may signal an enterovesical (bowel– bladder) fistula from diverticulitis,
Crohn’s disease, or neoplastic disease of the bowel.
• Nocturia occurs with ‘irritative bladder’, diabetes mellitus,
rhythm (seen in renal and cardiac failure).
• Once
is exc luded, haematuria is due t o neopl asia or glomer ulonep hritis (p
proven otherwise.
, and reversed diurnal
306
) until
57
2 History and examination
Examination of the abdomen
IBD
B
JVP
PBC
B
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58
Introduce yourself, obtain consent to examine, and position lying down as flat as
possible, conventionally exposing from ‘nipples to knees’. (In female patients delay
until examining the abdomen. In practice, maximize dignity: minimize intimate
exposure time needed for examination.)
1
Inspection
• General: ill/ well/ cachexic/ in pain?
• Colour: pale, jaundiced, uraemic, tattoos, acanthosis nigricans (axilla, groin).
• The ‘S’s: Shape, Scars, Stoma, Steroids (striae, Cushingoid, eg transplant/
• Ask the patient to lift their head or cough test: look for bulges, distension. If this
causes pain, suspect peritonitis.
• Targ e t ed in s p ec t i on f o r :
• Liver disease: jaundice, purpura, spider naevi, gynaecomastia, hair loss.
• Malignancy: cachexia, mass, anaemia, jaundice.
2
• Inspect Clubbi ng (p74), palmar erythema (fig
Dupuytren’s contracture (fig
• Nails See p75. Leuconychia in hy poalbuminaemia , koilo-
in i ron/
nychia
hypoalbuminaemia,
• Asterixis Negative myoclonus characterized by irregular
lapse of hand posture, due to metabolic (hepatic/ renal)
encephalopathy (may not be a useful test in a well patient).
Hands
2.38
2.24
), crease pigmentation.
/ folate deficiency, Muehrcke’s lines in
12
blue lunulae in Wilson’s disease.
3
Arms
, p75),
Fig 2.
contracture.
• Pulse (p40) and blood pressure.
• Forea rm AV fistulae (haemodialysis access in kidney
p
299
failure,
scratch marks.
• Inspect the distribution of the SVC (arms, upper
chest, upper back) for spider naevi (
), track marks, bruising, pigmentation,
fig
2.25
).
Fig 2.
25
Spider naevi.
24
Dupuytren’s
).
4
Neck
• Examine cervical and supraclavicular
fig
lymph nodes (
Tro is ie r’s si gn
cular node in gastric cancer).
•
: see p41. Raised in volume overload,
tricuspid regurgitation (examine for pulsatile hepatomegaly).
• Scars from tunnelled haemodialysis lines
p
299
) or other central venous access.
(
2.26
= enlarged left supraclavi-
• Eyes Jaundice, conjunctival pallor, xanthelasma (
Kayser– Fleischer rings = green- yellow ring at corneal margin in Wilson’s disease.
• Mouth Angular stomatitis (thiamine/
Jeghers syndrome,
hereditary haemorrhagic telangiectasia,
) (Virchow’s node/
p
695
, fig
15.9
), telangiectasia (Osler– We ber– Rendu syndrome/
Fig 2.
26
Cervical and supraclavicular nodes.
Reproduced from Thomas J, et al. (eds).
Oxford Handbook of Clinical Examination and
Practical Skills (
5
Fac e
/ iron deficiency), pigmentation (Peutz–
12
p
695
, fig
15.7
2014
), with permission from
Oxford University Press.
, chronic obstruction).
), ulcers, glossitis, hepatic fetor.
2 History and examination
6
AAA
IVC
RIF,
RIF
RUQ
RIF
https://t.me/med1917
Inspection
previous surgery, transplant, stoma. Check
Scars:
flanks for nephrectomy scars.
satile/ expansile
•
obs truct ion = blood flows up below umbilicus.
• Portal hypertens ion (caput medusae) = flow radi-
Abdomen
Masses: hernias, pul-
. Veins: assess direction of flow:
ates out from umbilicus.
Palpation (p
Squat so patient’s abdomen is at your eye level.
Ask if there is pain and examine painful area last.
Watch the patient’s face for discomfort.
Light palpation: if pain, check for rebound tender-
ness (increased pain on removing hand = peritoneal
inflammation). Any guarding (involuntary tensing of
abdominal muscles,
citis,
Liver: starting in
margin. Press down and ask patient to take a deep breath feeling for a liver edge.
Repeat, working towards the right costal margin. Assess size (
derness, pulsatility. Scratch test: place diaphragm of stethoscope at right costal
margin, gently scratch abdominal wall, starting in
increase in scratch transmission is audible at the liver border.
Repeat working towards the left costal margin. To help: roll the patient onto their
right side to tip the spleen forward while pressing from behind.
one hand in patient’s loin, pressing down on the abdomen from above and ‘ballot’
the kidney up with your lower hand against your upper hand (
pate midline above umbilicus, is it expansile (
563
)
Fig 2.
27
Ballottement of kidneys.
Reproduced from Thomas J, et al.
(eds). Oxford Handbook of Clinical
Examination and Practical Skills
(
2014
), with permission from
p
598
p
600
), Murphy’s sign (cholecystitis, p
)? Rovsing’s sign (appendi-
using radial border of index finger aligned with costal
626
). Deep palpation: to detect masses.
Oxford University Press.
p54), texture, ten-
working towards
Spleen: start in
. Press down and ask patient to take a deep breath feeling for edge of spleen.
Kidneys: place
fig
2.27
fig
2.49
, p82)?
). Aorta: pal-
Percussion (Some percuss first, before palpation to fully exclude pain.)
• Liver: percus s and m ap upp er & lo wer bor ders of liver.
• Spleen: percus s from border of spl een as pal pated, to mid - axillary line.
• Bladder: if enl arged, suprap ubic r egion will be dull.
• Ascites: shifting dullness (p
596
)— percuss from centre to flanks until dull, keep your
finger at the dull spot and ask patient to lean onto opposite side. If the dullness is
fluid, this will move with gravity and the dull area will become resonant.
Auscultation
• Bowel sounds: listen just below umbilicus. Absence = ileus. Enhanced and tink-
ling = bowel obstruction.
• Bruits: aorta, femoral and renal arteries (posteriorly, either side of midline, p82).
59
— an
Peripheral oedema
Rectum and anus Have a chaperone present. Explain. Use gloves and lubricant.
, external genitalia, and hernial orifices (p
Ask the patient to lie on their left side, with knees up towards the chest.
Inspect: haemorrhoids, subanodermal clot, prolapsed rectum (= descent of >
when asked to strain), anodermatitis from soiling, gaping anus (= neuropathy/
megarectum), asymmetry/ tender unilateral bulge (= abscess).
Anocutaneous reflex: tests sensory and motor innervation. On lightly stroking
the anal skin, does the external sphincter briefly contract?
Palpate: press index finger against the side of anus. Ask the patient to breathe
in and insert finger slowly. Feel for masses (haemorrhoids are not palpable), and
impacted stool. Then twist your arm so the pad of your finger is feeling anteriorly for cervix/ prostate. Note consistency, size, and symmetry of prostate. Ask
the patient to squeeze your finger and note the tone (best done with finger pad
facing posteriorly). Note stool/ blood on glove. Consider proctoscopy (anus) or
sigmoidoscopy (rectum). Test for occult blood in faeces.
7
Complete the examination
604
), dip urine.
3
cm
2 History and examination
ICP
OHCS
ENT
OHCS
ADL
CNS
ALGrawany
https://t.me/med1917
The neurological system: history
60
History From the patient, and whenever possible get a collateral history from
another observer of the neurological symptoms. The patient’s memory, perception,
or speech may be aected by the disorder. Note the progression of symptoms and
signs: gradual deterioration (eg slow- growing tumour) or intermittent exacerbations
(eg multiple sclerosis) or rapid onset (eg stroke). Note if right- or left- hand dominant.
Presenting symptoms
• Headache See p
Single/ recurrent? Unilateral/ bilateral? Associated symptoms (eg aura with migraine,
p
454
)? Meningism (p
Tak e a ‘ w o rs t - ever’ headache very seriously (p
• Muscle weakness See p
Any sphincter disturbance? Loss of balance? Associated spinal/ root pain?
• Visual disturbance Includes blurring, double vision (diplopia), photophobia, visual loss.
Speed of onset? Any preceding symptoms? Eye pain? See
• Other senses Hearing (p
consider also
• Dizziness See p
loss/ tinnitus? Any syncope (consider cardiac disease)? Positional?
• Speech disturbance See p71. Diculty in expression (expressive dysphasia), articula-
tion (dysarthria), or comprehension (receptive dysphasia)? Sudden or gradual?
• Dysphagia See p
ated pain (odynophagia)?
• Fits/ faints/ ‘funny turns’/ involuntary movements See p
helpful. Frequency? Duration? Mode of onset? Preceding symptoms/ aura? Loss of consciousness? Tongue biting? Incontinence? Any residual weakness/ confusion? Family
history?
• Abnormal sensation Eg n um bne ss, ‘pi ns & needles’ (paraesthesiae), pain. Distribution?
Speed of onset? Associated weakness?
• Trem or Rapid or slow? Present at rest? Worse with deliberate movement? - agonist
use? Thyroid disease/ symptoms (
muscle contraction)? Any family history?
Past medical history Meningitis/ encephalitis, head/ spine trauma, seizures, oper-
ations, risk factors for vascular disease (
betes, smoking), travel. Is there any possibility of pregnancy (eclampsia,
Drug history Anticonvulsant/ antipsychotic/ antidepressant medication? Any psy-
chotropic/ illicit drugs? Medications with known neurological side eects (eg isoniazid can cause a peripheral neuropathy)?
Social and family history What can the patient do/ not do, ie activities of daily
living (
atric disease? Consanguinity? Consider sexual history, eg syphilis.
Tremor
Tremor is rhythmic oscillation of limbs, trunk, head, or tongue. Classified as:
1
Resting tremor Worst at rest, usually a slow tremor (frequency 3– 5
ally ‘pill- rolling’ of the thumb over a finger, eg Parkinsonism (± bradykinesia and
rigidity, tremor is more resistant to treatment than other symptoms).
2
Postural tremor Worst if arms are outstretched. Typically rapid (8– 12
cludes exaggerated physiological tremor (eg anxiety, hyperthyroidism, alcohol,
drugs),
somal dominant tremor of arms and head, cogwheeling but no bradykinesia,
suppressed by alcohol, rarely progressive unless onset is unilateral. Propranolol
40– 80mg/ 8– 12
(
3
Intention tremor Worst on movement, seen in cerebellar disease, with past-
pointing and dysdiadochokinesis (
452
. Dierent to usual headaches? Acute/ chronic? Speed of onset?
806
)? Worse on waking (may suggest i
733
462
. Speed of onset? Muscle groups aected? Sensory loss?
459
dis ease.
458
246
), smell, taste? May not be due to neurological disease:
. Illusion of surroundings moving (vertigo)? Associated hearing
. To solids, liquids, or both? Intermittent or constant? Any associ-
)? Conscious level?
).
p
323
.
464
. A collateral history is
p29)? Fasciculation (spontaneous and involuntary
p
466
, AF, hypertension, hyperlipidaemia, dia-
S) and Barthel Index score? Any family history of neurological or psychi-
pathology (eg Wilson’s disease, syphilis), essential tremor (auto-
h PO) may help, but not in all).
p
495
).
p90)?
Hz), typic-
Hz). In-
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