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Systems review Relevant systems review will often be part of the HPC;
a thorough systems review is only necessary if you are unsure what is
relevant or are struggling to explain the symptoms. See Table3. and
E OHCM1p. 28.
Table3. Key symptoms toassess onsystemsreview
CVS Chest pain, palpitations, SOB, ankle swelling, orthopnoea
Resp Cough, haemoptysis, sputum, wheeze, SOB
Abdo Abdo pain, nausea/ vomiting, bowel habit, PR bleeding, stool colour and
consistency, distension, dysuria, urinary frequency/urgency, haematuria
Neuro Headache, photophobia, neck stiness, weakness, change in
sensation, balance, ts, falls, speech, changes in vision/ hearing
Systemic Appetite, weight loss/ gain, fever/ night sweats, malaise, sti/ swollen
joints, fatigue, rashes/ itch, sleep pattern
Summarizing Ask if there are any other problems that have not been
discussed and repeat back a summary of the history to the patient to
check that they agree (Box 3.). It is a good idea to use the ICE questions
(Ideas, Concerns, Expectations) at this point— ask the patient if they
have any idea or suspicion of what might be wrong with them, if there’s
anything in particular that they’re worried about (this may prompt them
to admit specic concerns, eg having cancer), and what they expect will
happen to them while they are in hospital. The art of ‘ICE’ is to ask naturally, so patients feel able to open up to you. Doing this while examining
the patient can work well forsome.
Most patients have no idea about tests and investigations and nd being
admitted to hospital a frightening event; they often value the opportunity
to talk about possible options and ask questions.
Always nish your history by asking specically if the patient has any
further questions or any other issues they would like to discuss, as frequently they will be too embarrassed/ shy/ reticent toask.
T Box 3. Should you take notes whileclerking?
There is no simple answer to this. Taking notes while the patient talks
may allow you to record important details accurately or even to write
up your clerking as you go. This can be extremely useful during busy
on- calls. Alternatively, not taking notes allows you to give the patient
your undivided attention and the opportunity to record the clerking
having considered the whole picture. In the end it comes down to individual preference and workload.
123BASIC HISTORY
After thehistory
By the end of taking the history you should have a reasonable idea of the
dierential diagnosis. Try to think of specic signs that would be present
on examination to conrm or refute these dierentials. Abasic examination is described in the next topic (Ep. 24).
124 CHAPTER3 History and examination
Basic examination
It is good practice to perform a brief CVS, RS, abdo, and neuro exam on all
patients but focus your examination according to their history. Check observations (temp, BP, HR, RR, O
• Ask a nurse to chaperone you if necessary
• Get consent before touching the patient, ask where ithurts
• First assess briey whether the patient looks well orill.
Hands(Ep. 50.)
InspectionOf the hands for signs of disease.
PalpationCheck the pulse for rate, rhythm, and character (eg ?collapsing pulse).
Mouth
Inspection Central cyanosis, mucous membranes, stomatitis, beefy
tongue (diron), candidiasis, ulcers, dental hygiene (risk factor forSBE).
Cardiovascular system(Epp. 26–7.)
InspectionMidline sternotomy or vein harvesting scars, JVP (very useful if
visible), swollen ankles.
Palpation Temp of hands, capillary- rell, carotid pulse (volume and char-
acter), apex beat, heaves/ thrills, hepatomegaly.
Auscultation Heart sounds, added sounds/ murmurs (timing, volume,
radiation), carotid bruits, basal crackles.
Respiratory system(Ep. 28.)
Inspection Asterixis (ap), stridor, JVP, RR and eort (accessory muscles,
recession), chest wall movement, thoracotomy scars, peripheral oedema.
Palpation Trachea, cervical lymphadenopathy, expansion.
PercussionSymmetrical, hyperresonant, dull, stonydull.
Auscultation Air entry, crackles, wheeze, bronchial breath sounds,rub.
Abdomen(Ep. 29.)
InspectionJaundice, scars, distension, hernias, oedema.
Palpation Start away from pain and watch patient’s face: tenderness,
peritonism (guarding, rebound, rigidity, percussion tenderness), masses,
liver, spleen, kidneys and AAA (expansile mass), hernias, ± genitalia, PR
(masses, stool, tenderness, prostate, blood/ mucus/ melaena).
Percussion Ascites (shifting dullness, uid thrill), liver, spleen.
AuscultationBowel sounds (absent, reduced, increased, tinkling).
Peripheral nerves(Epp. 32–4.)
InspectionPosture, movement oflimbs.
Palpation Tone; power (5 normal, 4 weak, 3 against gravity only, 2 not even
against gravity, twitch, 0 none); reexes (tendons, plantars); sensation.
CoordinationFinger– nose, slide heel down oppositeleg.
Cranial nerves(Ep. 31.)
Inspection GCS, mental state (E pp. 59–60), facial symmetry, scars,
obvious gaze palsies, speech, posture.
Eyes(II, III, IV, VI) Acuity, pupil reactivity, elds, movements,fundi.
Face(V, VII) Sensation andpower.
Mouth(IX, X, XII) Tongue movements, uvula position,cough.
Other(VIII) Hearing, balance, gait (XI), shrug, head movements.
sats):
2
Recording your clerking
The initial clerking of a patient is one of the most important steps in
their journey through the hospital. It will be reread by every team that
looks after the patient and used as a benchmark for measuring the progress of the patient’s condition. A good clerking gives the patient the
best opportunity to receive the correct investigations and treatment.
Heading Your name, position, location, date, time; state clearly why the
patient is being clerked (eg referred from ED with chestpain).
FormatFollow a logical order setting out each section under the head-
ingsshown in this topic. If a piece of information from a dierent section
is really important then write it in the history of presenting complaint
and/ or under the social history.
SourcesState where you got important information from (eg patient,
relative (with name and relationship), notes, computer records). This
makes it easy to check if the information is of critical importance.
Use thenotesDon’t rely on a patient’s account of their past medical his-
tory, especially for investigations and results. Try to nd the ocial record of
key investigations rather than relying on another doctor’s comments.
Be thorough These pages represent a basic clerking; you should re-
cord all of the information described on these pages at the very least. Use
‘NAD’ to record ‘nothing abnormal detected’ by all means, but do not be
tempted to write it for a system you have not examined properly (‘not
actually done’)— this is inaccurate and dishonest and even if the system
seems unrelated to the presenting complaint, may lead to problems later
if the patient subsequently develops an unexpected problem with that
system causing colleagues to refer back to the admission clerking.
State the obvious What appears obvious now may not be to
someone reading the notes or on the next shift, eg below- knee prosthetic leg, crying constantly.
Dierential diagnosis What diseases are likely to explain the
patient’s symptoms? What serious diseases need to be excluded? Make
a list of these after the examination. Consider recording the most critical
evidence for and against each diagnosis.
Management plan This should be a detailed list of the steps you will
take to diagnose and treat the dierential diagnosis. It should be written in
order of priority. Alongside investigations and treatment consider nursing
measures, frequency of observations, what to do in the event of deterioration, referrals, best location (eg respiratory ward, HDU). If you have
referred the patient to another specialty, record the name, bleep, and time
patient was accepted. Likewise if you have handed the patient over to a
colleague at a shift change.
State what the patient was told This prevents confusion. If you
are not telling the patient about a serious illness then statewhy.
E p. 76 for other tips about writing in thenotes.
125RECORDING YOUR CLERKING
126 CHAPTER3 History and examination
Cardiovascular
History
Symptoms Chest pain or heaviness, dyspnoea (exertional, orthopnoea, par-
oxysmal nocturnal) (Table3.2), ankle/ limb swelling, palpitations, syncope or
presyncope, limb pain (at rest or on exertion), fatigue, numbness, ulcers.
Past medical history IHD, MI, hypertension, palpitations, syncope, clot-
ting problems, rheumatic fever, cardiac surgery, recent dental work, liver
problems, renal problems, thyroid disease.
Drug historyCardiac medications (and compliance), allergies (and reaction).
Social history Tobacco, alcohol, and caeine consumption, illicit drug use
(?IV, cocaine), occupation, exercise tolerance on at and stairs.
Family history IHD, ilipids, cardiomyopathy, congenital heart disease,
sudden cardiacdeath.
Coronary artery disease risk factors Previous IHD, smoking, iBP, ilipids,
family history of IHD, DM, obesity and physical inactivity, malesex.
Table3.2 Functional classication ofheart failure(NYHA)
ClassI Disease present but no symptoms during ordinary activity
ClassII Angina or dyspnoea during ordinary activity (eg walking to shops)
ClassIII Angina or dyspnoea during minimal activity (eg making cup of tea)
ClassIV Angina or dyspnoea at rest
Source:data from Dolgin M, etal. Nomenclature and criteria for diagnosis of diseases of the
heart and great vessels, 9th edition, Lippincott Williams and Wilkins (Boston:MA), 994, and
Criteria Committee, NewYork Heart Association, Inc. Diseases of the heart and blood vessels.
Nomenclature and criteria for diagnosis, 6th edition, Little, Brown and Co. (Boston:MA),964.
K Box 3.2 Palpation ofcentral and peripheralpulses
Central
Carotid Two ngers, medial to the sternocleidomastoid muscle and
•
lateral to the thyroid cartilage (do not palpate both sides together)
•
Abdominal aorta Fingertips of both hands, applied halfway between
umbilicus and xiphisternum.
Arms
•
Radial Two ngers pressed on the radial aspect of the innerwrist
•
Ulnar Two ngers pressed on the ulnar aspect of the innerwrist
•
Brachial Two ngers pressed into the antecubital fossa, just medial
to the biceps tendon (ask patient to ex arm against resistance to
nd the tendon).
Legs
•
Femoral Two ngers pressed rmly into the middle of the crease in
the groin, halfway between the symphysis pubis and the anterior
superior iliacspine
•
Popliteal Ask patient to ex their knee, put both your thumbs either side
of the patella and press rmly with your ngertips into the poplitealfossa
•
Posterior tibial Two ngers pressed cm posterior to the medial malleolus
•
Dorsalis pedis Two ngers pressed between the st and 2nd metatarsals.
Examination (lying at45°)
General inspectionDyspnoea at rest, cyanosis, pallor, facial ushing, Marfan’s,
Turner’s, Down’s syndromes, rheumatological disorders, acromegaly.
Hands Radial pulses (right and left, collapsing pulse) (Box 3.2), clubbing,
splinter haemorrhages, Osler’s nodes, peripheral cyanosis, xanthomata.
Face Eyes (pallor, jaundice, xanthelasma), malar ush, mouth (cyanosis,
high- arched palate, dentition).
NeckJVP, carotids (pulse character) (Box3.2).
PrecordiumInspection (scars, deformity, apex beat), palpate (apex beat,
thrills, heave (Table3.3)), auscultate (heart sounds (HS; Table3.4),
murmurs— also auscultate with the patient in both left lateral and sitting forward positions).
BackScars, sacral oedema, pleural eusions, pulmonary oedema.
Abdomen Palpate liver, spleen, aorta, ballot kidneys, percuss for ascites,
femoral and renal artery bruits, radiofemoraldelay.
Legs Peripheral pulses (Box 3.2), temperature, ulceration, oedema, calf
tenderness, venous guttering, thin shiny skin, loss of hair, gangrene, varicose veins, eczema, haemosiderin pigmentation of the skin (particularly
above the medial malleolus), lipodermatosclerosis (‘inverted champagne
bottleleg’).
Blood pressureLying and standing, consider also left and right arms separately.
OtherUrine analysis, fundoscopy, temperaturechart.
Table3.3 Characteristics ofvalve defects
Mitral
stenosis
Mitral
regurgitation
Aortic
stenosis
Aortic
regurgitation
Mid- diastolic rumbling murmur, loud st HS, opening snap,
malar ush, AF, tapping apex, left parasternal heave
Pansystolic murmur radiating to the axilla, soft st HS, 3rd HS
present, thrusting apex, left parasternal heave
Ejection systolic murmur radiating to the neck, 4th HS,
reversed HS splitting, slow rising pulse, systolic thrill
Early diastolic murmur (best heard in expiration), collapsing
pulse, wide BP, pistol- shot femoral pulse, Corrigan’s sign,
Quincke’s sign, de Musset’s sign
127CARDIOVASCULAR
Table3.4 Heartsounds
st (S) Physiological; blocking of blood ow after closing of the mitral (M)
and tricuspid (T
) Physiological; blocking of blood ow after closing of the aortic (A2)
2nd (S
2
and pulmonary (P
can be heard during inspiration
3rd (S
) Sometimes pathological; caused by blood rushing into the ventricles
3
after S
or heart failure
4th (S
) Pathological; blood pushing open a sti ventricle before S; suggests
4
LVF, aortic stenosis, cardiomyopathy
) valves
) valves; aortic precedes pulmonary and splitting
2
; suggests increased volume of blood in athletes, pregnancy,
2
128 CHAPTER3 History and examination
Respiratory
History
Symptoms Cough, sputum, shortness of breath, wheeze, chest pain,
haemoptysis, fevers and sweats, weight loss, hoarseness, snoring, day
sleepiness (obstructive sleep apnoea).
Past medical history Chest infections/ pneumonias (as child or adult), tu-
berculosis (TB), HIV status and risk factors, allergy, rheumatoid disease.
Drug historyRespiratory drugs (inhalers, steroids, etc), vaccination history
(especially BCG, Hib, pneumococcus), drugs known to cause respiratory
problems (bleomycin, methotrexate, amiodarone, etc), allergies.
Social history Tobacco use (expressed in pack- years— ie 20 cigarettes/ d
for yr =pack- year) and social exposure to tobacco smoke if nonsmoker, pets, exposure to other family members with respiratory problems (TB etc), illicit drug use (crack cocaine, cannabis).
Occupational history Past and present jobs, asking specically about dust
exposure, asbestos, animal dander.
Family history Asthma/ atopy, cystic brosis, emphysema.
Examination (lying at45°)
General inspection O
rate and depth of respiration, use of accessory muscles, body habitus.
Hands Clubbing, peripheral cyanosis, tar staining, wasting/ weakness of
intrinsic muscles, HR, ne tremor of β- agonists, apping tremor of CO
retention.
FaceEyes (Horner’s syndrome, anaemia), mouth (central cyanosis),voice.
Neck Trachea position (± scars),JVP.
Chest anteriorly Inspect (shape, scars, radiotherapy marks), palpate
(supraclavicular nodes, axillary nodes, expansion, vocal fremitus, apex
beat, parasternal heave), percuss, auscultate.
Chest posteriorly Inspect, palpate (including cervical nodes), percuss,
auscultate.
OtherPeripheral oedema, calf erythema/ tenderness, temperature chart,
breast examination (if suspect malignancy), abdominal examination,
peak expiratory ow rate (PEFR; Box 3.3), sputumpot.
requirements, cough, audible wheeze or stridor,
2
2
K Box 3.3 RecordingPEFR
Ensure the meter is set to zero and t a new disposable mouthpiece.
Stand the patient up (or sit up if unable to stand) and give them clear
instructions. They should take as deep a breath as possible, before placing the meter in their mouth and closing their lips around the mouthpiece. Encourage them to blow out as hard and as fast as possible.
Record the reading obtained, then document the best of three eorts.
Gastrointestinal
History
Symptoms Abdo pain, association with eating, vomiting, or opening bowels,
weight loss, appetite, bruising, bleeding, nausea, vomiting ( appearance), dysphagia, odynophagia, dysuria, urinary frequency and urgency, possibility of
pregnancy.
on passing, recurrent urge, blood (bowl or paper), oensive smell,mucus.
Past medical historyGI bleeds, GORD, varices, gallstones, liver problems,
jaundice, IBD, haemorrhoids, polyps, blood transfusions.
Drug history NSAIDs, anticoagulants, hepatotoxic drugs (E p. 70),
opioids, laxatives, recent antibiotics (Clostridium dicile).
Social historyForeign travel, illicit drug use (?IV), sexual history.
AlcoholIntake per day (in units, E p. 22), CAGE questions (Ep. 380).
Family historyIBD, liver disease, cancer.
Examination (lying at onback)
General inspection Oedema, wasting, jaundice, anaemia, lymphadenop-
athy, breath odour, mouth ulcers, gynaecomastia, spider naevi, bruises.
HandsClubbing, nail colour, palm colour, ap, Dupuytren’s.
AbdomenDistension (fat, faeces, atus, uid, foetus), prominent veins, ten-
derness (guarding, rebound), masses, organomegaly (Tables3.5 and 3.6),
ascites, hernial orices (inguinal, femoral, incisional), bowel sounds.
PRVisible haemorrhoids, ssures and skin tags, anal tone, prostate, rectal
masses, appearance of faeces ±blood.
Table3.5 Common abdominal masses— if indoubt, check withUSS
Liver RUQ, extends to RLQ, unable to get above, dull to percussion
Spleen LUQ extends to RLQ, unable to get above, notch
Kidney RUQ and/ or LUQ, ballotable, able to get above it, smooth outline
Faeces Indentable mass away from umbilicus
StoolChange in bowel habit, frequency, consistency, colour, pain
129GASTROINTESTINAL
Table3.6 Common causes ofenlarged liver andspleen
Hepatomegaly Alcohol, hepatitis, EBV, CMV, thin patient, autoimmune
Splenomegaly Chronic liver disease, autoimmune disease,
Hepatosplenomegaly Hepatitis, EBV, CMV, chronic liver disease, leukaemia,
hepatitis, toxins, liver metastases, lymphoma, leukaemia,
haemochromatosis, amyloidosis, hyperexpanded chest,
eg COPD, heart failure
thrombocytopenia, EBV, CMV, hepatitis, HIV,
haemolytic anaemia, leukaemia, lymphoma,
endocarditis, thalassaemia, sickle cell, myelobrosis,
sarcoid, amyloidosis, malaria, leishmaniasis
lymphoma, myelobrosis, amyloidosis
130 CHAPTER3 History and examination
Neurological
History
Presenting complaint Onset, duration, course (improving, worsening, re-
lapsing– remitting), aggravating or alleviating factors, change with time of
day, trauma.
SymptomsHeadache, pain, numbness, tingling, weakness, tremor, twitching,
abnormal movements, loss of consciousness, seizures, abnormal smells,
vision (loss, diplopia, ashing lights), hearing, swallowing, speech, balance,
vertigo, nausea, vomiting, coordination, urinary incontinence or retention,
impotence, faecal incontinence, constipation, personality, memory, language, visuospatial skills, change in intellect.
Collateral historyIn many neurological conditions the patient may not be
able to describe all the symptoms, eg seizure; try to get a history from a
witness or family member. Do they have a video?
Past medical history Similar episodes, meningitis, migraines, strokes, seiz-
ures, heart problems, hypertension, DM, psychiatric problems.
Drug history Neurological drugs (eg antiepileptics, Parkinson’s medi-
cations— note down the timings carefully), psychiatric drugs (eg
antipsychotics, antidepressants), all others (especially cardiac and hypoglycaemic drugs).
Family historyDraw a family tree with all four grandparents and all their
children and grandchildren, ask specically about learning diculties, disability, epilepsy, dementia, CVAs, psychiatric problems.
Social history Alcohol, smoking, illicit drugs, occupation, travel abroad,
dominanthand.
Examination
The neurological examination should determine if the pattern is UMN,
LMN, or mixed and guide localization and subsequent investigations
(E p. 355). It is typically broken down into cranial nerves, upper limb
and lower limb. Cranial nerves are usually examined in order as per
Table 3.7 while tone, power, reexes, sensation, and coordination form
the essentials of the upper and lower limb examination.
ObsGCS, BP (lying and standing), HR, RR, glucose.
General appearancePosture, neglect, nutrition, mobilityaids.
Cognition Tested using the Mini- Mental State Exam (E p. 385) or
0- point Abbreviated Mental State Exam (Ep. 383).
Meningism Photophobia, neck stiness, Brudzinski’s sign (involuntary
exion of hips and knees when neck exed due to neck stiness),
Kernig’s sign (unable to straighten leg when hip fully exed in supine
patient), straight leg raise (hamstring spasm on passively exing thehip).
SkinBirthmarks, vitiligo, café- au- lait spots, ash leaf macules, lumps, tufts
of hair/ dimples at the base of thespine.
See Table3.7 for cranial nerve examination, and Fig.3..
Table3.7 Cranial nerve examination
Visual cortex
Left
Homonymous hemianopia
Nerve Function Tests
Olfactory
Optic
(Fig.3.)
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Accessory
Hypoglossal
I
Smell Rarely tested
II
Vision Visual acuity, visual elds,
III
Eye movements, lift the
eyelid, pupil constriction
IV
Superior oblique Move eye down and out
V
Sensation to face,
movement of jaw
muscles
VI
Lateral rectus muscle Move eye laterally
VII
Facial muscle movement,
taste (anterior ⅔),
salivary and lacrimal
glands, stapedius muscle
VIII
Hearing and balance Whispering numbers, Weber’s
IX
Taste (posterior ⅓),
parotid gland, sensation
of pharynx, nasopharynx,
middle ear
X
Sensation of pharynx
and larynx, movement of
palate, pharynx, larynx
XI
Movement of
sternomastoid and
trapezius
XII
Movement of tongue Stick
pupil reexes, fundoscopy
Eye movements, pupil
reexes
Facial sensation, jaw power,
corneal reex
Facial power
(forehead), Rinne’s (behind ear)
Saying ‘Ahh’, swallow, gag
reex
Saying ‘Ahh’ (uvula deviates
away from defect), cough,
swallow, speech, gag reex
Shrug shoulders, turn head
towards defect), speech
131NEUROLOGICAL
tongue out (deviates
Visual eld
Right
1
4
2
3
5
6
Optic nerve
Optic chiasma
Lateral geniculate
nucleus
Optic radiation
Normal
Fig.3. Optic pathways and eect of a lesion on the visual elds at various
locations.
RightLeft
1 Unilateral vision loss
2
3
4
5
6
Normal elds
Bitemporal hemianopia
Homonymous hemianopia
Upper quadrantanopia
Lower quadrantanopia
(with central sparing)
132 CHAPTER3 History and examination
Upper and lower limb examination
Appearance Posture, tremor, muscle wasting, fasciculation, abnormal
movements, facial expression and symmetry, neglect.
Hold outhandsWith palms up and eyes closed; look for drift (pyramidal
defect), tremor, or involuntary nger movement (loss of position sense).
To ne Tone at wrist, elbow, knee, and ankle (increased, decreased, clasp
knife, cog- wheeling), clonus at the ankle (≥5 beats is abnormal).
Power Isolate each joint with one hand so that only the muscle group
you are testing can be used for the movement; compare each side
(Table3.8). See Table3.9 for root levels of main limb movements.
ReexesDeep tendon reexes comparing each side (Table3.0)— if absent ask
the patient to clench their teeth (reinforcement); plantar reexes— upgoing big
toes on stroking the sole is the Babinski sign and points to an UMN lesion.
Table3.8 Medical Research Council (MRC) grading ofmusclepower
Grade 0 No movement
Grade Flicker of movement
Grade 2 Movement but not against gravity
Grade 3 Weakness but movement against gravity
Grade 4 Weakness but movement against resistance
Grade 5 Normal power
© Crown Copyright. The Aids to the Examination of the Peripheral Nervous System
(Memorandum No. 45)is licensed under the Open Government Licence 3.0. Used with the
permission of the Medical Research Council.
Table3.9 Root levels ofmain limb movements
Joint Movement Root Joint Movement Root
Shoulder Abduction C5 Hip Flexion L– 2
Adduction C5– 7 Adduction L2– 3
Elbow Flexion C5– 6 Extension L5– S
Extension C7 Knee Flexion L5– S
Wrist Flexion C7– 8 Extension L3– 4
Extension C7 Ankle Dorsiexion L4
Fingers Flexion
Extension
Abduction
C8
C7
Big toe Extension L5
T
Plantarexion S– 2
Table3.0 Tendon reexes
Grading of tendon reexes Root levels of tendon reexes
0 Absent
± Present with reinforcement Bicep C5– 6 Knee L3– 4
+ Reduced Supinator C5– 6 Ankle S– 2
++ Normal Tricep C7– 8
+++ Increased
++++ Increased with clonus
Reex Root Reex Root