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ChestCVS and RS examination (pericarditis, heart failure, uid overload).
Uterus
Fallopian
Outer labia
m duct)
(testicles)
Bladder
LegsOedema, bruising, pigmentation, scratch marks, neuropathy, prox-
imal weakness (myopathy), altered reexes, muscle wasting.
UrinalysisGlucose, blood, protein, nitrites, leucocytes.
OtherFundoscopy (DM and iBP changes), blood glucose, weight.
153UROLOGICAL
tube
Ovary
Bladder
Pubic bone
Clitoris
Inner labia
Cervix
Rectum
Anus
Vagina
Urethral
meatus
Pubic bone
Urethra
Shaft
Glans
Foreskin
Urethral
meatus
Scrotum
Seminal
vesicles
Rectum
Prostate
Anus
Vas deferens
(sper
EpididymisTestis
Fig.3.20 Anatomy of the female (L)and male (R)urogenital systems.
Examination ofmale genitalia
Always have a chaperone who can reassure the patient and also guard the
door. Document name and role in notes. Ask friends and family members
to leave, unless the patient wants them to stay (this also provides an opportunity to ask questions which the patient may not have answered fully
with others present). As with any examination it is essential to keep the
patient informed about what you are going to do.
Inspection Look for any ulceration (including retracting foreskin and
checking the glans), warts, scars, or sinuses, urethral discharge, tight
foreskin (phimosis) or retracted foreskin which is stuck leaving the glans
exposed (paraphimosis). Inspect the scrotum for skin changes or oedema and, while the patient is standing, the lie of the testes (the left testis
usually hangs lower than the right and both testes lie longitudinally— a
high testis with a transverse lie may indicate torsion, though a torted
testis may also appear normal).
Palpateeach testis in turn between the ngers and the thumb feeling for
texture, tenderness, nodules, and to compare left to right. An absent
testis may be maldescended and trapped in the inguinal canal. Examine
epididymis and follow it up superiorly to the spermatic cord and up into
the inguinal ring. Palpate inguinal lymph nodes or maldescended testis.
Examination offemale genitalia See Epp. 54–5.
154 CHAPTER3 History and examination
Female reproductivesystem
History
Menstrual history Date of last period, length of menstrual cycle (regular or
irregular), length of period, associated pain/ symptoms (Box 3.9), age when
periods started/ stopped; bleeding/ discharge severity of periods (number
of pads/ tampons, clots, ooding), bleeding between periods, after intercourse (vaginal, anal, oral), or after menopause, rectal/ urinary bleeding,
eect on lifestyle, other vaginal discharge (colour, consistency, and smell).
Sexual historyPain on supercial or deep penetration (dyspareunia), type
of intercourse (vaginal, anal, oral), use of contraception, intercourse in
foreign countries, previous sexually transmitted infections;
Current and previous types, problems/ benets.
Cervical smearDate of last test and result, previous results, and any treat-
ment (repeat smears, colposcopy clinic, laser ablation).
Past gynae history Previous problems and/ or operations (where and
name of surgeon), breast or thyroid problems, use of HRT, prolapse.
Past obstetric history Number of pregnancies, number of births, type of
delivery, complications, subfertility (E p. 56 for obstetric history).
Past medical historyClotting problems, thyroid problems, anaemia, malignancy.
Urinary problemsIncontinence (on laughing/ coughing/ exercising or spon-
taneous), dysuria, urgency, frequency, haematuria; if symptomatic ask
about uid intake, leg weakness, faecal incontinence, back pain and previous spinal problems/ surgery, eect on lifestyle.
OtherVaginal lumps, weight loss, other concerns.
Examination
Always have a chaperone who can reassure the patient and guard the
door. Document name and role in notes. Ask accompanying persons to
leave, unless the patient wants them to stay (also provides opportunity
to ask questions which the patient might not answer fully with others
present). It is essential to keep the patient informed about what you are
going to do. Start with the patient lying on her back with arms by sides. It
is important that you have a good examination lamp. See Fig.3.2.
Abdominal Assess for scars, striae, hernias, body hair distribution, everted
umbilicus, distension, tenderness including loins (± guarding, rebound),
masses, organomegaly, percuss (masses, shifting dullness). Ask patient to
move feet apart, bend knees, and let legs op outwards. Have a strong
light source directed at the vulva and gloves on both hands.
VulvalLook for rashes, ulcers, warts, lumps, or other lesions; spread the
labia majora using your non- dominant thumb and index nger and look
for lesions, lumps, discharge (urethral/ vaginal), bleeding; ask the patient
to push down (look for prolapse) andcough.
VaginalInsert a well- lubricated index and middle nger (dominant hand)
into the vagina and feel for the cervix, noting the size, shape, consistency,
and whether it is mobile or tender. Feel above, below, and to the sides
(adnexae) for masses or tenderness. Finally, palpate the uterus by placing
your other hand above the pubic symphysis and press down with the
ngers at the cervix; pressing up feel for uterine position (anteverted/
retroverted), size, shape, consistency, mobility, and tenderness. Inspect
the nger afterwards for blood or discharge.
Contraception
Cusco’s speculum While the patient is in the same position, insert a
Bladder
Pubic bone
well-lubricated and warmed speculum into the vagina. Look at the
cervix. If you are unable to visualize the cervix, ask the patient to tilt
her pelvis forward by placing her sts under her bottom. Look for ulceration, bleeding, cysts or other lesions, and the cervical os. If required
take swabs and/ or a cervicalsmear.
ConsiderSims’ speculum (for examining prolapses), rectal examination.
Uterus
Fig.3.2 Examination of the female reproductive system.
K Box 3.9 Descriptive terms ingynaecology
Anatomy
Adnexae The areas lateral to the cervix where the ovaries are located.
Introitus The entrance to the vagina.
Abnormal bleeding
ClimactericPhase of irregular periods and associated symptoms prior
to menopause.
IntermenstrualBleeding between periods.
Menopause The end of a woman’s menstrual cycles.
MenorrhagiaExcessive blood loss during menstruation (>80mL/ cycle).
OligomenorrhoeaInfrequent menstruation, >42d menstrualcycle.
PostcoitalBleeding after sexual intercourse.
PostmenopausalBleeding >6mth after the menopause.
Primary amenorrhoeaFailure to start menstruating by6yr.
Secondary amenorrhoea Absence of menstruation for >6mth after
menstruation has started and not due to pregnancy.
Pain
DysmenorrhoeaPain associated with menstruation.
DyspareuniaPain associated with sexual intercourse, can be supercial
(eg vulval or entrance to vagina) or deep (only on deep penetration).
155FEMALE REPRODUCTIVE SYSTEM
Clitoris
Rectum
Cervix
156 CHAPTER3 History and examination
Obstetric
History
Current pregnancy Estimated due date (EDD), gestation, last menstrual
period (LMP), method of conception, scan results, site of placenta,
rhesus status, concerns, attitude to pregnancy;
other vaginal discharge, headache, visual disturbance, dysuria, urinary
frequency or urgency, constipation, vomiting,GORD.
Previous pregnanciesNumber of pregnancies (gravidity), number of deliv-
eries ≥24/ 40wk (parity), miscarriages, terminations (reason, gestation,
method), stillbirths, complications:vomiting, anaemia, bleeding, group
B strep, BP, proteinuria, gestational DM, poor foetal growth, admission.
Delivery history Method of delivery and reason (vaginal, ventouse, forceps,
elective/ emergency Caesarean), gestation, birthweight, sex, complications
(fever, prolonged rupture of membranes, CTG trace), postnatal baby problems (feeding, infection, jaundice), admission to SCBU/ NNU, outcome
(how is the child now), postnatal maternal problems (pain, fever, bleeding,
depression).
Past gynae historyPrevious problems, operations,STIs.
Past medical historyDVT, PE, DM, admissions, psychiatric problems.
Drug history Antihypertensives, antiepileptics, insulin. Many drugs are
contraindicated or used with caution in pregnancy.
Family historyDM, iBP, pre- eclampsia, congenital abnormalities, DVT, PE,
multiple pregnancies.
Social historySupport from family/ partner, type of housing, employment,
nancial problems, smoking, alcohol, substanceabuse.
Table3.4 Antenatal care (uncomplicated pregnancies)
Gestation
(wk)
Booking FBC, G+S, red cell antibodies, syphilis, hepatitis B, HIV serology,
– 4 USS for gestational assessment and nuchal screening (combined test)
6 BP, urine
8–20 Urine, BP, serum screening (for Down’s and neural tube defects;
28 Fundal height, BP, urine, FBC, red cell antibodies, anti- D if
25
34 Fundal height, BP, urine, anti- D if rhesus– ve
36, 38, 40
4 Discuss induction, foetal position, fundal height, BP, urine, oer
*
For further information, see Mwww.nice.org.uk/ guidance/ng20
†
For the rst pregnancyonly.
Standard antenatal care:purpose of each visit*
sickle- cell disease, thalassaemia, BMI, BP, urine dipstick and culture
quadruple test), USS for foetal anomalies and placental position
rhesus–ve. Oer pertussis vaccine
†
, 3†Fundal height, BP, urine
†
Foetal position, fundal height, BP, urine, oer ECV if breech at 36/ 40
membrane sweep
Current symptomsBleeding,
Examination
s
s
s
s
s
Foetal heart Audible from 2wk using a Doppler ultrasound and 24wk
using a Pinard stethoscope; it is faster than the mother’s (0– 60bpm).
Weight Plot mother’s weight and BMI (E p. 632) at the booking visit
(Table3.4).
Inspection Striae, linea nigra (line of pigmentation from the pubic sym-
physis to the navel that darkens during the st trimester), venous distension, scars, oedema.
Fundal height The fundus (top of the uterus) is palpable from about 2wk
gestation; it should be measured from the top of the pubic symphysis to
the top of the fundus with a tape measure. Between 6 and 36wk the
fundal height in centimetres should be the same as the gestation ±2cm,
eg 23– 27cm at 25wk. Fundal height is unreliable after 36wk. See Fig.3.22.
Foetal lie After 32wk it is possible to assess the position of the foetus by
palpating across the abdomen for the foetalhead:
•
Longitudinal Head palpable in midline
•
Oblique Head palpable in iliacfossa
•
Transverse Head palpable in lateral abdomen.
PresentationPalpation after 32wk can also assess the presentation though
this is liable to change until about 36wk. By palpating both ends of the
foetus the position of the head can be determined:
•
Cephalic Head is at thebottom
•
Breech Head is at thetop.
Engagement This is assessed by palpating the base of the uterus above
the pubic symphysis between two hands to assess how much of the
presenting part is palpable. If only the top / 5th of the presenting part is
palpable the foetus has ‘engaged’.
Blood pressure This must be monitored regularly to assess for pregnancy-
induced iBP; consider urine dipstick and fundoscopytoo.
Urine dipstickFor protein (pre- eclampsia) and glucose(DM).
USSLie, presentation, and engagement can be conrmed onUSS.
157OBSTETRIC
36 week
40 week
Fig.3.22 Location of the fundus as pregnancy progresses.
22 week
16 week
12 week
158 CHAPTER3 History and examination
Psychiatric
History
Are you safe?Sit so the patient is not between you and the door, remove
all potential weapons, be familiar with the panic alarm, check notes/ ask
sta about previous violence, have a low threshold for a chaperone.
Set thescene Make sure you are both comfortable, ensure privacy and
that you will not be disturbed, eg give the bleep to someone else, have
tissues available, emphasize condentiality.
BasicsFull name, age, marital status, occupation, who were they referred
by, current status under Mental HealthAct.
Past psychiatric history Previous psychiatric diagnoses, in- patient/ day
patient/ out- patient care, do they have a community psychiatric nurse
(CPN), previous deliberate self- harm, previous treatments and eects,
ever been admitted under the Mental HealthAct.
Medication historyCurrent and previous medications, eects, did they/ do
they take it, allergies/ reactions, alternative/ herbal remedies.
Personal history
• Childhood Pregnancy, birth, development (E p. 62), associated
memories, names of schools attended, reason if changed schools,
types of school (mainstream/ specialist), age of leaving school,
qualications
•
Employment Loss of jobs, which did they enjoy, why did they change, ask
about unemployment andwhy
•
Relationships Current relationship(s) and sexual orientation, list of
major relationships and reasons for ending, any children and who they
live with and relationship to patient.
Forensic Contact with police, convictions or charges, sentences, out-
standing charges.
Personality How would they describe their personality now and before
the illness? How would others describeit?
Social history Occupation and duration of employment/ unemployment,
where they live, concerns over money, friends and relationships, hobbies.
Drug and alcoholSmoking, alcohol, illicitdrugs.
Family historyFamily tree with parents and siblings, ages, occupations, re-
lationships, illnesses.
Examination
Psychiatrists examine the mind through talking to the patient (Boxes 3.0
and 3.). Much of the information is gleaned while taking the history and
should be organized under the following headings. This is called the Mental
State Examination(MSE).
Appearance Racial origin, age, dress, make- up, hairstyle, jewellery, tat-
toos, cleanliness, neglect, physical condition.
Behaviour Appropriateness, posture, movement (excessive, slow,
exaggerated), gestures, tics, facial expression, eye contact, anxiety, suspiciousness, rapport, abnormal movements, aggression, distraction, concentration.
Mood The patient’s subjective assessment of theirmood.
AectInterviewer’s objective assessment of mood and appropriateness
of patient’s response, eg at, reactive, blunted.
Speech form Accent, volume, rate, tone, quantity, hesitations, stuttering;
Content Associations (derailment, changing between subjects),puns.
Thought formRate, ow (eg blocked), connection (eg ight of ideas, derail-
ment);
ContentBeliefs about self, beliefs about others, thought insertion/
withdrawal/ control/ broadcast, beliefs about the world/ future, delusions,
overvalued ideas, obsessions, compulsions, ruminations, rituals, phobias.
PerceptionIllusions, hallucinations (visual, auditory, tactile, olfactory), un-
usual experiences, depersonalization, derealization.
Cognition This can be tested formally using the Mini- Mental State
Examination (MMSE) on E p. 385; often the Abbreviated Mental Test
Score (AMTS) is used instead (Ep. 383).
Risk Thoughts of deliberate self- harm, suicide, harming others, plans, ac-
quiring equipment, writing notes, previous suicide attempts. Can ‘protective factors’ be identied? Document theseif so. Consider risk both
to self and to others.
Insight Awareness of illness and need for treatment.
159PSYCHIATRIC
K Box 3.0 Dening ‘mental illness’
What constitutes abnormal behaviour to the extent of constituting
a mental illness can be a controversial and dicult area, subject to allegations of cultural and political bias and even suggestions of undue
pharmaceutical industry inuence. Two main classication systems are
accepted:
• The Diagnostic and Statistical Manual of Mental Disorders, produced
by the American Psychiatric Association; the 5th edition (203) is
currently in use:DSM- 5
• The International Classication of Diseases, published by the World
Health Organization (covers all of medicine); th edition (209) is
currently in use:ICD- .
Each classication carries a slightly dierent emphasis and diagnostic
criteria; in rare instances, this results in an abnormal condition recognized in one, but not theother.
160 CHAPTER3 History and examination
K Box 3. Common terms inpsychiatry
Aect Pattern of observable behaviours which reects emotions
experienced.
AnxietyFeeling of apprehension caused by anticipation of perceived danger.
Approved clinician A doctor entitled to recommend compulsory admis-
sion for treatment under the 2007 Mental HealthAct.
Cognition The process of thinking, reasoning, and remembering.
Compulsion Repetitive behaviours in response to obsessions; often to
relieve the distress caused by them, eg washinghands.
Delirium Acute onset of disordered cognition with attentional decits;
typically involves changes in arousal and may be associated with hallucinations. Typically uctuating.
Delusion A xed, false belief that goes against available evidence and is
not explained by the person’s religious or cultural background.
Dementia Global organic deterioration of cognition with preserved
consciousness.
Depersonalization Altered sense of self as if detached or outside thebody.
Derealization Altered sense of reality as if detached from surroundings.
Emotion A complex state of feeling that results in physical and psycho-
logical changes that inuence thought and behaviour.
EuphoriaPathologically exaggerated feeling of well- being.
Flight ofideasRapid switching of topics where the thread of connection
can be determined (eg sound, content).
Formal admission Admission under a section of the Mental HealthAct.
Hallucination A false sensory perception in the absence of a real stimulus,
eg hearing voices; feature of psychosis if the subject lacks recognition of
the false nature.
Illusion False interpretation of a real external stimulus, eg seeing a
shadow and thinking it is a person.
Informal admissionVoluntary admission as a psychiatric in- patient.
Insight The ability of a person to recognize their mental illness.
Mania Abnormal elevation of mood with grandiose ideas, increased en-
ergy and agitation, pressure of speech, distractibility, and pleasure seeking.
MoodEmotional state that colours the person’s perception of theworld.
ObsessionRecurrent unwanted thoughts or images, eg my hands aredirty.
Passivity Delusional belief in external control of a person’s actions or
thoughts.
Personality disorder Enduring and inexible behavioural patterns that
markedly dier to societalnorms.
PhobiaPersistent, irrational fear of an activity, object, or situation, leading
to the desire to avoid the feared stimulus; beyond voluntary control.
Psychosis Disordered thinking and perception without insight, often
accompanied by delusions or hallucinations.
Ruminations A compulsion to consider an idea or phrase.
StereotypeRepeated pattern of movement or speech without anygoal.
Thought insertionDelusional belief by a person that an external agency
is putting thoughts into his/ her mind (a passivity phenomenon).
Neonatal examination
The baby check is a key component of life in paediatrics. All neonates
should be examined within 72h of birth with the aimof:
• Identifying unwell babies (tone and respiratory rate very important)
• Identifying abnormalities (especially reversibleones).
Preparation Prior to the examination you should check the maternal
notes for: signicant maternal illness, gestation at birth, birthweight, type
of delivery, problems at delivery (meconium, premature rupture of membranes (PROM), group B strep, low APGAR scores: appearance, pulse,
grimace, activity, respiration).
IntroductionIntroduce yourself to the mother/ parents, oer congratu-
lations and explanation. Has the baby passed faeces and urine? Feeding
well? Any parental concerns? Ask them to undress the baby to thenappy.
$ Settledbaby Consider doing the following rst as they are di-
cult if the baby is crying:listening to the heart and feeling the apex beat,
count RR, feeling the femoral pulse, and looking in theeyes.
$ Cryingbaby Try getting the baby to suck (pacier, breast, bottle,
parent’s little nger, your little nger); if this fails, swaddle the baby and
ask the parents to give the baby a feed then return in30min.
Overall Take a few moments just to look; is the baby:jaundiced, blue,
dysmorphic, moving normally, breathing normally?
Neuro To ne (Degree of head support, spontaneous symmetrical limb
movements), Moro reex is not routinely performed.
Head Anterior and posterior fontanelle (bulging, sunken), head circum-
ference, eyes red reex (red ag if absent), face (dysmorphic?), ear shape
and position (tags, pits, top of insertion of pinna should be at the level of
the eyes), palate (with your little nger), suck reex.
Hands/ armsFingers (number, shape, colour), palms (single crease in
60% of Down’s and % of non- Down’s), symmetrical arm movement.
ChestRespiratory rate (RR >60 is abnormal), listen to the heart, apex
beat, gently feel the clavicles for fractures.
Abdo Palpate (to exclude hepatomegaly, splenomegaly, masses), des-
cended testes, patent anus, enlarged clitoris, femoral pulses.
Hips/ feet Anterior hip creases (symmetrical?), Barlow test (ex hip to
90°, press posteriorly, feel for a click/ clunk if the hip dislocates), Ortolani
test (after Barlow’s abduct the hips one at a time while pressing on the
greater trochanter with your middle nger, feel for a click/ clunk as the hip
relocates), note repetition of these tests can cause hip instability, ankles
(talipes, correctable or not), toes (number, shape, colour).
Turn baby overSpine (straight), sacrum (lumps, dimples, hair tufts, skin
defects), buttocks (blue spots— make a note), posterior hip creases.
PlotIn the red book:weight, head circumference, examination.
161NEONATAL EXAMINATION
162 CHAPTER3 History and examination
Paediatric
History
Basics Age in days (until mth), weeks (until 2mth), months (until 2yr), or
years, sex, who gave the history, who was present.
Current stateFeeding and drinking, weight gain, wetting nappies/ passing
urine, fever, bowels, crying, runny nose, cough, breathing problems,
pulling ears, drawing up legs,rash.
BirthPregnancy problems and medications, gestation at birth (37– 42/ 40
is normal), type of delivery (NVD, induced, ventouse, forceps, if LSCS
ask why), resuscitation, special care, birthweight, PROM, group B strep
(GBS), meconium, maternal pyrexia during labour, vitamin K (IM or oral),
feeding (breast, bottle, type ofmilk).
ImmunizationsCheck the child is up to date with vaccinations (Table3.5);
jabs will be postponed if the child is unwell or febrile beforehand and
children often get a slight fever for <24h afterwards.
Table3.5 UK vaccination schedule (from June2020)
Birth May get TB (BCG) and/ or hepatitis B if at risk
2mth Diphtheria, tetanus, pertussis, polio, and Haemophilus
3mth Diphtheria, tetanus, pertussis, polio, and Haemophilus inuenzae
4mth Diphtheria, tetanus, pertussis, polio, and Haemophilus
2– 3mth
2–8yr Inuenza
3yr4mth– 5yr Diphtheria, tetanus, pertussis, and polio (DTaP/ IPV), MMR
2– 3yr Human papilloma virus
4yr Tetanus, diphtheria, and polio (Td/ IPV) and meningococcal
Source:data from Mhttps://www.gov.uk/government/publications/the-complete-routine-
immunisation-schedule Contains public sector information licensed under the Open
Government Licencev3.0.
DevelopmentSee Table3.6 and ask about school performance.
Social history Who the child lives with, parental responsibility, parental
jobs, smoking, nursery/ school attendance, type of school (mainstream,
special needs), academic ability, sporting ability, friends, enjoyment of
school, foreign travel.
Family historyFamily tree with parents and siblings, consanguinity if rele-
vant, illnesses in the family, how are their parents and siblings at the moment, asthma, eczema, hayfever, DM, epilepsy, other diseases specic to
presenting complaint.
inuenzae type b (DTaP/ IPV/ Hib), hepatitis B, rotavirus,
meningococcal group B (MenB)
type b (DTaP/ IPV/ Hib), hepatitis B, rotavirus, pneumococcal
inuenzae type b (DTaP/ IPV/ Hib), hepatitis B, MenB
Measles, mumps, rubella (MMR), Haemophilus inuenzae type B
(Hib), pneumococcal, meningococcal group C disease (MenC),
MenB
groups A, C, W, and Y disease