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MB ChB Clinical History and Examination Manual

This is derived from the “Green Book”, a typewritten aide memoire for clinical examination well known to all Glasgow graduates. It is intended as an aid to learning clinical history taking and examination, specifically in Phase 3 of the MB ChB curriculum - the first 15 weeks of Year 3. During that time, students will spend one full day per week in or in General Practice. The hospital session should involve: (a) a session of bedside teaching, involving history taking and examination; (b) a case (either alone or in pairs) which should then be hand-written in the format at the end of this booklet; (c) presentation and discussion of the cases as a group. For the first few sessions it is expected that only parts of the history and examination will be covered but by the end of Year 3 all students should be proficient. Additional sections cover history-taking in , and that are relevant later in the MB ChB programme. 3 Index

Introduction 5 The Abdominal Systems (GIS, 33 The ’s problem 5 GUS and Haematological)

The Doctor’s problem 6 The Nervous System 37

History 8 History & Examination in 43 Joint History of Presenting 9 Complaint (HPC) Examination of the Patient 45 with a Skin Complaint Cardiovascular System 10 Summary Plan for Taking 46 11 History and in the Adult Gastrointestinal System 12 Physical Examination:- 48 Genitourinary System:- 15 Cardiovascular System For Females Respiratory System For Males Alimentary System Nervous System Central Nervous System (CNS) 16 Locomotor system Skin Endocrine System 17 Urinalysis Haemopoetic System Summary Skin Special Systems 49 Musculoskeletal System History Taking in Obstetrics 49 Past History 18 and Gynaecology Family History Drug History History and Physical 50 Social and Personal History Examination of the Infant and Child Examination 19 History in Psychiatric Disease 57 Systematic Examination 19 Mental State Examination 59 Behavioural Symptoms 63 Physical Examination 20 NOTES 64 Specific Components of the 20 General Examination

The Cardiovascular System 22

The Respiratory System 29

4 Introduction The Patient’s problem

The clinical manifestations go to a doctor of disease are: because - Symptoms: Something the patient feels • they are alarmed by their or observes themselves, which they symptoms and believe themselves to regard as abnormal, e.g. pain, vomiting be ill or weakness of a limb. These are • they seek an explanation of and discovered by taking a “history”, which relief of their symptoms means a clinical “interrogation” or • they want to recover to their dialogue between doctor and patient. previous as rapidly as possible, by adopting the treatment Signs: Physical or functional advised by their doctor and hope the abnormalities elicited by physical cure will be a permanent one examination, e.g. tenderness, • they and their relatives wish to know a swelling felt by or a the probable course and outcome change in a tendon reflex. of the illness, the effectiveness of treatment available and whether any complications or sequelae will follow the disease. • they need help and guidance in the management of chronic . • they require the interpretation of results.

Caution: Patients may be alarmed by use of common phrases that might be part of a junior student’s but are unlikely to apply to the individual being examined. You should avoid use of words like ‘’ or ‘tumour’ - using neoplasm or mitotic disease instead. Other avoidable terms and their suggested replacements would be AIDS / HIV (‘retroviral ’), enlarged (‘’), enlarged liver (‘’), leukaemia (‘white cell disorder’).

5 The Doctor’s problem It depends on the assembly of all the relevant facts concerning the past and present history of the illness, together The doctor wants to know the meaning with the condition of the patient, as of the patient’s symptoms and of the shown by a full clinical examination. signs which are elicited, in order to Simple laboratory tests, such as recognise the disease or diseases examination of the urine or estimation from which the patient is suffering of the haemoglobin content of the (diagnosis). Knowledge of the disease blood, can be carried out by the doctor and of its course in others allows himself. For most patients referred the doctor to forecast the outlook to hospital, more elaborate special (prognosis) and to prescribe treatment investigations are necessary, such as (). radiological examination and special biochemical investigations. Pre-symptomatic diagnosis: In many patients the presence of Prognosis: disease may be detected as a result of (outcome of an illness): This depends population screening, or the targeted on the nature of the disease, on its population of specific groups. This is a severity and on the stage of the disease major role of General Practice in the UK reached in the particular patient. It and includes, for example, recording also depends on the constitution, of in all registered occupation and economic status of patients, cervical screening and the individual patient, as well as his breast screening of selected patient motivation and ability to collaborate in groups. Routine testing of patients treatment. Prognosis may be expressed with a family history, for example, of statistically in terms of percentage colonic carcinoma or adult polycystic chances of recovery or of death in kidney disease, is another strategy. acute illness, or of average expectation Increasingly this may involve genetic of life in chronic diseases. These testing. estimates must be based on experience gained by the study of large numbers Patients may also engage in screening of comparable patients and must be at their own initiative, and often at applied with the greatest caution to their own cost. For example, patients individual patients. may obtain a whole body CT scan or, perhaps in the future, a whole genome Syndrome: scan and present with the results of the A syndrome is a combination of investigation. This is likely to increase in symptoms and/or signs which the future and produces challenges for commonly occur together, e.g. clinicians. malabsorption syndrome, consisting of chronic diarrhoea with fatty stools and Diagnosis: multiple nutritional deficiencies. An interpretation of symptoms and signs leading to identificationof a disease (or diseases). A complete description involves knowledge of the causation (aetiology) and of the anatomical and functional changes which are present.

6 Patient Safety and Comfort Note: History taking and physical examination If you retain a patient history, or submit can be a very exhausting experience it as a teaching case, it must not be for the patient. Remember, also, that the identifiable to third parties. The patient’s patient may already have been seen confidentialitymust be retained. by other students. For these reasons it Thus, it is common practice to use the is essential, before taking a history initials and a Hospital Number. When or conducting a physical examination, recorded in the Hospital Case record, to ask if the patient feels able and the full details should be written down. willing to cooperate. Throughout the In many , electronic records examination the patient’s comfort or admission pro-formas are used. should be kept constantly in mind. However, all students should be able Movement of the patient should be to take a full history and examination, restricted as much as possible; for and not to be reliant (or limited) to the example when the patient is sitting use of electronic resources. forward the opportunity should be taken to palpate the neck, examine the chest posteriorly and look for sacral oedema and spinal deformity, e.g. kyphosis and scoliosis.

7 History

Source of history:

Name:

Age:

Hospital Number:

Occupation (including past occupations with dates):

Domicile (present and past):

Date of admission/ examination in case of out patients (to which all subsequent dates are related)

Marital status/ next of kin:

Presenting Complaint:

PC: The PC should be given briefly in patient’s own words, as far as possible. For example: “”.

Duration: in hours, days, months or years, not “since ‘Monday” etc.

If more than one PC, enumerate in order of importance: (1); (2); (3)…

8 History of Presenting (b) Symptomatic, or systematic enquiry Complaint (HPC) After the patient has given a general description of his illness, the system (a) General description mainly involved will usually, but by no The taking of an accurate history is means always, be obvious. The patient the most difficult and, in the majority of should then be questioned about the medical diseases, the most important main symptoms produced by diseases part of a consultation. It becomes of this system. This should be followed progressively simpler as the clinician’s by enquiries directed towards other knowledge of disease and experience systems. It should be remembered increases. that the classificationof symptoms by systems is one of convenience and The history of the present condition is not absolute e.g. breathlessness may extend over days, weeks, months may arise from disease of the cardiac, or even years and should be recorded respiratory, renal or central nervous chronologically. As far as possible, system. The following list of symptoms the patient’s own account should be and suggested lines of questioning is written down, unaltered by leading not comprehensive and is intended questions but phrased in medical as a simple guide for beginners. With terms. When the patient’s own experience, and specialist teaching, phraseology is used the words should students will enhance and focus be written in inverted commas, e.g. questioning for individual systems “giddiness”, “wind”, “palpitation” and and presentations. an attempt should be made to find out precisely what they mean to the patient. The order of onset of symptoms is important. If there is doubt about the date of onset of the disease, the patient should be asked when he last felt quite well and why he first consulted his doctor. Dates may be quoted absolutely or relative to the date of writing e.g. five days ago; but if the latter system is used the date on which the history is written must be clearly shown. Notes of any treatment already received and of its effect, if any, must be made.

9 Cardiovascular Dizziness • whether associated with change System in posture, or palpitation • whether true Breathlessness • whether associated with collapse • on exertion only (noting degree of or loss of consciousness exertion) • faints • also at rest, if wakes at night (eg paroxysmal nocturnal dyspnoea, Peripheral vascular PND) symptoms • duration, severity, precipitating • intermittent claudication – pain in factors, orthopnoea, number of the calves or buttocks on exertion, pillows used relieved by rest. Exercise limit, on flat ground and stairs. Pain in chest • cold feet or hands – association • onset - on exertion or at rest, with temperature. Associated or associated with activity, such as , pain or dysasthesia or change in posture (Raynaud’s phenomenon). • character - sharp, crushing or “tight” • rest pain – pain in muscles or feet • site • radiation • duration • exacerbating and relieving factors (e.g. drugs such as GTN) • a ccompanying sensations (e.g. breathlessness, vomiting, cold sweats, pallor, reflux, heartburn) • pecipitating factors - cold, heavy meal, emotion

Oedema • ankle swelling - time of day • abdominal swelling - tightness of trousers or skirt

Palpitation • patient conscious of irregularity or forcefulness of heart beat • character of palpitation – patients may tap out the rhythm

10 Respiratory System Hoarseness • change of voice with or without pain • duration • duration? • character • site of pain - pharynx or neck • productive (of ) or not? “Sore throat” • frequency • causing, or associated with, pain? Nasal discharge or • associated with symptoms of obstruction infection? • one or both nostrils • watery or purulent? Sputum • blood (epistaxis), note – may result • quantity in haematemesis if blood swallowed • colour • type (frothy, stringy, sticky) Loss of weight • w hen most profuse (during the day, • time course night, the time of year and the effect • appetite: food intake of posture) • p resence of blood (haemoptysis) Is Sweating the blood red or brown? (i.e. fresh or • day or night old). Streaked with blood/ clots? • requiring change of clothes? • Is it purulent? • associated with other symptoms of infection? Breathlessness • on exercise or at rest Smoking • exercise limit – on flat, on stairs • cigarettes, cigars? • relationship with posture • ? • Diurnal variation • duration (packets/day x years = PACK YEARS) • precipitating factors, (cough, fog, Occupation emotion, change of environment, • high risk occupations – e.g mining, contact with animals or birds, time farming, shipyards of year) • type of dust? asbestos? • Diurnal variation duration

Pain in chest • site • character • relationship with respiration (pleuritic)? • relationship with coughing?

11 Gastrointestinal Difficulty in swallowing System (dysphagia) • duration - continuous or intermittent; progressive • fluids or solids, or both? • duration • painful or painless? • character - burning, gnawing, • level at which food “sticks” colicky etc. • nausea - continuous (e.g. hepatitis, • site , uraemia); or intermittent • depth • related to food (type), e.g. neoplasm, • radiation gastritis, disease (fatty • frequency – continuous, periodic, foods) continuous with exacerbations • related to posture, e.g. • timing and association - nocturnal • vomiting, preceded, or not, by pain (awakening in early hours), nausea? (distinguishes gastric relationship to eating from cerebral vomiting, which is not • aggravating and relieving factors preceded by nausea) – e.g. food, milk, alkalis, • character - small, repeated, bowel action, posture projectile; related to food, pain, • relationship with micturition, special foods retention of urine, menstrual cycle, menstruation Vomitus • remote or • amount • rectal pain • colour – clear, bile stained, coffee • back pain – pancreatic, adherent grounds, fresh blood posterior peptic ulcer • content - undigested food (e.g. taken • shoulder tip pain (due to days or many hours before in pyloric diaphragmatic irritation) - gall obstruction) bladder disease, perforation • chest pain – oesophagitis Belching • headache – migraine, abdominal • eructation of gas through mouth migraine (aerophagy)

Appetite Flatus • loss of appetite - distaste • passage of gas rectally disturbance for food (anorexia); “fear” of eating – pain, weight gain Flatulence (anorexia nervosa) • discomfort caused by excessive • increased appetite – obesity, gaseous distension pregnancy, hyperthyroidism

12 Distension Diarrhoea • abdominal enlargement causing • increase in frequency of defaecation, tightness of skirt or trousers (due to as compared with patient’s normal distension with flatus, fluid, fat, foetus frequency - usually accompanied by or faeces (5 F’s)) looseness of stools which may be • indigestion liquid or semi-formed • flatulent, painful, regurgitant • associated abdominal or rectal pain? • contact or possible source of Reflux infection - specific foods, restaurants, • regurgitation of bitter fluid into mouth foreign travel, friends or family which may be stained with bile or members with similar symptoms, certain food drug ingestion, e.g. antibiotics • spurious - secondary to severe Water brash constipation in elderly (“overflow diarrhoea”) • regurgitation of tasteless or salty fluid to mouth Stools Heartburn • Hard? Small? Pencil shaped? Pellets? • burning sensation behind sternum which may be intermittent; related • semi-formed – “ porridgy”, liquid to posture (reflux); continuous and • large, bulky (high fibre ) prolonged (oesophagitis) • colour - black (melaena, iron, bismuth); clay Weight loss coloured (obstructive jaundice); • usual weight; present weight; yellow (steatorrhoea) amount lost • abnormal constituents – • over what period; rate of loss blood (on surface or toilet paper • patient may present with ‘loose - haemorrhoids); blood, (mixed with stool - colitis, dysentery); clothing’ mucus; pus; steatorrhoea (stools bulky, yellow, offensive, difficult Alteration in bowel habits to flush away, leaving greasy • enquire into patient’s normal stain on lavatory pan) bowel habits, which may vary in normal individuals from three times Disturbance of function daily to twice weekly • urgency Constipation • sense of incomplete emptying • incontinence • reduction in frequency of defaecation as compared with patient’s normal state, usually Piles/haemorrhoids accompanied by hardening of stools • how long present? • how infrequent? • painful? • consistency of stool? • bleeding? • discomfort or straining? • prolapsing? • rectal pain? • constipating drugs

13 Jaundice • urine dark, pale stools, sclera and skin yellow • constant, fluctuating or progressive? • itching?

Miscellaneous • sore tongue? coated tongue? swollen tongue? • bad breath (halitosis)? • dry mouth?

Malabsorption • oedema? • skin lesions? purpura? • bone pain? • anaemia? symptoms of anaemia?

14 Genitourinary System Dyspareunia (pain during intercourse) Bladder • frequency - during day and/ Incontinence or night (nocturia) • stress (e.g. on coughing)? • flow rate, volume • continuous? • retention • dribbling Contraceptives • urgency/strangury/precipitancy (in drug history) • pain (dysuria) • enuresis (bed wetting) History of • Outcome, including Urine (spontaneous or therapeutic), • colour – clear, turbid, blood with dates. Usually written as Para (haematuria) x+y (Parity - where x is the number • smell of completed and y the number of • passage of stones, grit failed / incomplete pregnancies). • loin pain • – gestational age, associations (e.g. fetal malformation, • site, character, radiation pre-eclampsia) (e.g. to groin) For Males Oedema • ankles, dependent oedema Specific questions • , • impotence • facial, peri-orbital swelling • urethral discharge – purulent, For Females mucoid, blood-stained • prostatism – poor urine stream Menstruation retention of urine, nocturia • prostatitis – pain at end of • age at onset (menarche) micturition • age at cessation () • injuries • menses – regularity, duration, volume, pain (dysmenorrhoea)

Intermenstrual discharge • character e.g. purulent, blood stained • intermenstrual pain (site, character etc.) • date of last menstrual period • prolapse

15 Central Nervous Numbness or “pins and needles” in limbs or System (CNS) elsewhere (paraesthesiae) • loss of sensation? Handedness • smoking, or cooking, burns of fingers? Loss of consciousness • sudden – warning; tongue biting; Dizziness / giddiness injuries sustained; passage of urine/ • rotational vertigo? incontinence;duration after effects; • clumsiness? precipitating cause; relief with food • dropping things? (sugar) • difficulties in movement? Mental state Visual disturbance • memory – short and long term • seeing double (diplopia)? • independent opinion of relative • dimness of vision? or friend should be sought • ‘Zig-zag’ figures (fortification • hallucinations spectra)? • agitation • visual field defect? • delusions • intellectual changes Headache • character • lateralised? • site • high or low pitched sounds? • duration • history of noise exposure? • associated symptoms – vomiting • (ringing in ears) • aggravating or relieving symptoms - time of day, change in posture, straining (e.g. defaecation, Sphincters micturition) • incontinence, faecal, urinary • retention of urine? Weakness or paralysis of limbs or any muscles Speech disturbance • sudden • duration • gradual • onset – sudden, gradual • progressive • nature – dysphasia, dysarthria • distribution

Abnormalities of gait • dragging leg, dragging or drop foot, wearing out toes of shoes? pattern of shoe wear • rolling or staggering; on side? dominant side?

16 Endocrine System • ankle swelling • Hair • intermittent claudication alterations in hair growth – baldness; hirsutism – distribution of hair (male Skin pattern etc.) Occupation Weight • weight gain/time Exposure to irritants, drugs, • weight lost /time sunlight • weight at key ages Rashes • appetite • type • situation Specific questions • duration • thirst and polyuria ( • treatment? insipidus) • painful? • changes in skin, voice and bowel • itching (pruritus)? habit (e.g. hypothyroidism – coarse skin, dry skin and hair, weight gain Pigmentation and hoarseness) • distribution? • temperature preference • neck swelling Musculoskeletal • pigmentation • sweating System • visual disturbance (fields) • flushes Swelling of joints • growth abnormality • one joint or multiple joints, • symmetry, distribution • libido Pain Haemopoetic System • time of day? • effect of exercise? Sore tongue • flitting (from joint to joint) or fixed? • pernicious anaemia Stiffness Blood loss • effect of exercise? • menorrhagia • morning stiffness? • haemorrhoids; obvious upper or lower GI bleeding; haematuria Mechanical dysfunction • in terms of normal activity Pallor • standing, walking, activities of daily Bruising living (ADL – e.g. combing hair) Symptoms of anaemia • tiredness Previous bone or joint injury • breathlessness • recent or distant past? •

17 Past History Drug History

• Illnesses (with dates): ask • any , taken in the past specifically about childhood and for current illness , tropical infections, • current medications should be listed , diabetes, TB, jaundice accurately, with the dose and timing and epilepsy – note, if absent e.g. Amlodipine 10mg o.d. • operations Also include “over-the-counter” • injuries (OTC) , such as • vaccination ibuprofen • insurance examination • ask about and record any adverse • obstetric and menstrual history drug reactions/ • ask about recreational drug use. Family History

• number and health of children Social and Personal • health of partner History • any similar or serious illness in parents, grandparents, siblings • occupation - whether employed or • longevity of family members: cause unemployed of death • location, type, size of house (where • in “genetic disease” construct necessary)- the need to climb stairs, family tree for example, may prevent patients Very often, valuable information about returning to their own house the patient’s complaints, family history • family circumstances, e.g. housing, and social background can be obtained living with parents, number of by interview with relatives. This is dependents always essential in paediatric practice, • hobbies and recreations and often essential in adult , • tobacco (cigarettes, cigars, pipe) for example, when the patient is unable – present smoker or ex-smoker to communicate. (record number of years). Calculate “Pack Years” – packets per day x years • - weekly amount, type, past history of alcoholic intake (note importance of reliable corroboration). Calculate units per week • Physical exercise - number of times per week on average • Duration of exercise on average - intensity: mild/moderate/intense (advice is for minimum of 5 x 30 minutes of moderate exercise per week)

18 Systemic Examination For students this is the most difficult part, as it requires training to interpret new auditory associations. The examination should now proceed to examination of the systems in turn – This auditory experience may be cardiovascular, respiratory, abdominal acquired most rapidly by listening (GIS, GUS), neurological and so forth. day after day to the same abnormality, The following is a summary of what in the same or different patients. is found in textbooks and includes the more important physical signs. It is not exhaustive but will still be a For most purposes the bell-shaped considerable challenge to students chest piece is preferable and should early in their careers. It is important be used particularly to identify low pitched sounds and murmurs, chiefly at to remember that it will take years to the apex. The diaphragm type of chest become proficient in examination and piece is better for picking up high- to identify clinical signs, many of which pitched murmurs and in amplifying are uncommon. low intensity (“distant’) breath sounds. In general, cheaper quality To begin with it is important to go (of the type provided through the examination process for blood pressure measurement) carefully and to gain experience of normal signs as, much as abnormal are inadequate for detecting murmurs. ones. A basic diagnostic (e.g. Littman Classic) is essential. The systematic examination follows a sequence: • inspection • palpation • that is helpful in remembering the signs to be elicited. It is, however, not merely a process to be gone through. It is important to try and piece together the signs that have been identified, and to predict the signs to be found from the history and general examination. For each system the first step is inspection. This takes experience to interpret the significance of what is seen. This is followed by palpation with the warm hand(s), followed by percussion to determine the position, size and state of the underlying organs. Finally, auscultation (with a stethoscope) is carried out.

19 Physical Examination Many of these features may have been noticed during the history taking. With experience, this may help direct and Initial general examination focus history taking and examination. In many patients more can be learned A complete physical examination from the initial general examination should now be conducted, system by than from separate examination of the system, beginning with the one which, various systems, which will follow. as judged by the history, is most likely to be involved. Before carrying this out, 1. note the temperature, rate it is wise to focus on certain special and , especially areas of the body which are apt to any change in these since the day be overlooked during a systematic of admission. examination. These are now described. 2. assess severity of illness, nutritional state, dehydration 3. presence or absence of distress Specific Components (including type of distress, e.g. pain, of the General cough, dyspnoea etc.) Examination 4. mental state (orientated, lethargic, drowsy, comatose etc.) Eyes 5. constitution • expothalmos (sclera seen below iris); physique – obese/thin, muscular, fit/ widening or narrowing of palpebral unfit looking, evidence of weight fissure, retraction of upper lid, lid loss, cachexia? lag, ptosis (unilateral, bilateral) skeletal – height, weight, constant or worse as day goes on proportions, any obvious (e.g. myasthenia gravis) deformities. • sclera – colour 6. psychological state – anxious, • conjunctive – pallor, congestion. irritable, depressed presence or absence of squint 7. facies – flushed, pallor, puffiness, (strabismus) hirsute 8. general colouration of skin and Nose mucosae - pallor, pigmentation, jaundice • movements of alae nasi 9. cyanosis - lips, nails, mucosae • discharge 10. oedema – dependent (legs, • tenderness over the paranasal lumbosacral, periorbital, abdominal, sinuses ascites), generalised (anasarca) • breathing through nose or mouth 11. skin - sweating, rash, loss of elasticity or of subcutaneous fat, nodules, spider naevi, purpura

20 Mouth Breasts • angles of mouth – fissuring, chelitis • examine for evidence of tumours, • tongue – moistness, furring, cysts or inflammation. presence, absence or flattening of papillae, fissuring, colour, wasting, Hands . • Clubbing of fingers – excessive • teeth – shape; loss of teeth, caries curvature of nails in longitudinal and cavities. If no teeth are dentures axis with obliteration of worn and do they fit well? angle between finger and base • gums – hypertrophy, retraction, of nail and sometimes a “drumstick” pus appearance of finger tip; fluctuation of • fauces – reddening of pillars, tonsils the nail bed. – size and exudates? • nails – “spoon-shaped” (koilonychia); • pharyngeal wall – condition; post- brittleness; ridging; pitting; nasal discharge? white opaque nails with loss of • mucosa – ulceration, pigmentation. lunules (leuconychia). • Heberden’s nodes – osteoarthritic Neck nodules at the distal interphalangeal • increased folds of skin from loss joints. of weight • swelling of joints • examine for large lymph glands – • wasting of muscles palpate successively submandibular, • colour of the hands occipital, cervical and supraclavicular • anaemia; cyanosis (only indicative groups. of anoxia if warm); “liver palms” The size, tenderness, mobility or palmar erythema (bright red and consistency of palpable glands colour of thenar and hypothnar should be noted. eminences and pulp of fingers). • neck (see later) • temperature of hands – e.g. warm moist hands of thyrotoxicosis; cold Thyroid cyanotic hands of peripheral • normal size or enlarged? circulatory failure; dry puffy hands in • If enlarged – does it move on myxoedema swallowing, uniform or asymmetrical, • tremor – fine or coarse smooth or nodular, present? • Swellings – if any swelling (tumour) • After initial inspection, palpation is found it should be examined and of thyroid is often best carried the following noted: out while standing behind • Site, shape, size, consistency, patient and allowing them to drink surface, texture, tenderness, from a glass of water to assess the temperature, translucency, mobility, effect of swallowing. fluctuation, whether attached to skin.

Axillae, groins and epitrochlear regions • examine for enlarged lymph nodes and note type of enlargement as outlined above.

21 The Cardiovascular Volume This depends on the output of the System heart, on the state of the vessel walls and on the amount of peripheral Pulse vasoconstriction. It may be described This refers to the radial pulse. as large, normal or small volume. The following should be checked: Character Rate The pulse is “quick rising” when there is Count over a 15 second period. increased peripheral vasodilatation, e.g. An increased rate is called in hyperthyroidism, fever, anaemia and (over 100/minute) and a decreased after exercise. This phenomenon rate, (under 60/minute). is most marked in severe aortic There is a wide range of rate in normal incompetence where the quick rise individuals. When gross irregularity, and fall give a rough indication of the due to atrial , is present degree of incompetence. The pulse the at the apex should be in this condition is also called “water- counted with a stethoscope for 30 hammer”, “collapsing” or “Corrigan” seconds. The difference between this (after the who first described figure and the radial pulse rate is called it). It is of large volume and is best the “pulse deficit”. recognized by holding the anterior aspect of the patient’s wrist in the palm Rhythm and elevating the patient’s arm. Regular or irregular? An increase In the pulse is of small in the pulse rate during inspiration volume and is slow rising, sustained and decrease during expiration is and slow falling. physiological and is called “sinus ”, most marked in childhood. Condition of vessel wall The vessel should be compressed If irregular, note whether a dominant to empty it of blood and rolled under underlying rhythm is present. the fingers. It should be described If a regular rhythm is interrupted as palpable or impalpable, hard or by beats out of place, or if beats are soft. This sign is difficult to ellicit and missed, the irregularity is probably interpret. due to extrasystoles.

If the rhythm is completely irregular and the beats are unequal in volume, the irregularity is probably due to the presence of – “irregularly irregular” – although it may be due to frequent extrasystoles. Exercise aggravates the irregularity of atrial fibrillation. (ECG) is often necessary to determine the true nature of an arrhythmia or of persistent tachycardia or bradycardia.

22 Blood Pressure Venous pressure Blood pressure should always be Inspection of neck veins is used to measured by a sphygmomanometer. obtain evidence of raised venous Air should be released from the cuff pressure. The internal jugular is slowly and steadily. The tactile method used and preferably the right since this of estimating systolic BP may be used is almost a direct continuation of the to determine the level to which the cuff superior vena cava, and no valves. should be inflated, i.e. the level of BP This is a difficult sign to detect – at which the radial pulse disappears. essentially one is looking for the effect On auscultation over the brachial of changes in the diameter of a large at the antecubital fossa, the first sound vessel on the overlying tissues. to be heard gives the systolic BP. Further lowering elicits sounds The patient should be sitting in a becoming increasingly loud and this semi- reclining position and the vein is followed by a sudden muffling looked for along a line joining the angle (Phase 4), and disappearance of the jaw and the sternoclavicular joint. (Phase 5). The latter is taken to The neck must be positioned to relax represent the diastolic level. the appropriate sternomastoid muscle. Note any variation in Systolic pressure between alternate The internal is beats (pulsus alternans). seen as a soft undulation and a double peak can often be identified. It is easily Peripheral obliterated by finger pressure, unlike Palpate the main vessels - radial, the carotid artery. The vertical height of brachial, carotid, femoral, popliteal, the venous column above the sternal dorsalis pedis and posterior tibial - angle (junction of the manubrium sterni to get some idea of the integrity of with the sternal body at the level of the the peripheral arterial tree. The pulse second costal cartilage) is measured should be readily palpable at all these and normally this is not greater sites in normal individuals. Compare than 3 cm. the volume of the radial and femoral , especially in the investigation Increased venous pressure is usually of hypertension (“radio-femoral delay”). evidence of right-sided . Auscultation over the carotid arteries, Pressure over the abdomen may to identify a bruit, is indicated when increase the degree of venous filling the patient presents with symptoms (hepatojugular reflux). Giant systolic suggestive of cerebral ischaemia. (“V”) waves may be seen in tricuspid Examine the state of the retinal vessels incompetence. Venous overfilling in (as part of the neurological system). the neck without pulsation occurs in superior vena cava obstruction. Veins The veins in the legs are examined to detect varicosities or for evidence of thrombosis. By far the most important sign involving the veins is the determination of the venous pressure in the neck.

23 Oedema Observe any abnormal movement Cardiac oedema develops first in the of the chest wall, or of the sternum, dependent parts of the body. coinciding with the heartbeat. Observe The earliest evidence of its presence any pulsation at the base of the heart. should be looked for in the lumbo- Note also pulsation in epigastrium sacral area if the patient is in bed and due to right , aorta, or rarely, at the ankles if the patient is ambulant. pulsating liver. The presence and site of The characteristic sign is ‘pitting any surgical thoracotomy scars should be noted. (firm pressure with the fingers causes small depressions which remain when the finger pressure is removed). Palpation Define the (the point on Heart Failure the chest wall furthest outwards and downwards where the cardiac impulse As well as increased venous pressure, can be distinctly appreciated). Measure other signs of heart failure should from midline - it lies normally in the be looked for. In right heart failure 4th or 5th space 3½” (7 cm) or less an enlarged liver and dependent from the mid-line in adults with patient oedema may be found and if tricuspid upright. It should lie within a vertical line regurgitation is present the liver may drawn downwards from the centre of pulsate. Crepitations in the lungs are found in left heart failure and are often the clavicle (the mid-clavicular line). accompanied by dyspnoea. A may be present. The position of the apex moves with change of posture. In disease the apex Examination of the heart beat may be displaced by increase in size of the heart or by change in Evidence of function is obtained from the lungs (collapse, , symptoms and from signs, such as , fibrosis of lungs). Place dyspnoea at rest, increased venous the flat of the hand over the apex and pressure, oedema, liver enlargement then over the base. The character of the and cyanosis. The physical signs impulse may be “localized” or “diffuse”, derived from an examination of the or no impulse may be detected; chest give information concerning the heart’s size and the state of the valves. it may he “heaving”, “slapping” or accompanied by a series of vibrations Inspection (thrill). Note that assessment of the trachea is essential to determine Note any deformity which might affect whether any deviation of the apex the position of the heart or affect its beat from its normal position is due to function e.g. pigeon chest, funnel chest, mediastinal shift. kyphoscoliosis. The normal cardiac impulse is localised to a small area Finally, with the flat of the hand, just inside the mid-clavicular line (for palpate also the left parasternal area in definition see under palpation) in the expiration to detect presence of 4th or 5th intercostal spaces, as a definite outward movement of the chest right ventricular ‘heave”, which occurs wall. Observe whether the impulse in right ventricular hypertrophy is localised or diffuse and note its situation.

24 Percussion The second sound is accentuated at The position and character of the the aortic area in systemic hypertension apex beat is the best way of assessing and at the pulmonary area in pulmonary cardiac size clinically. Cardiac hypertension. Both sounds may be percussion is not performed. muffled in the presence of obesity, emphysema or . Auscultation of the heart Either sound may be split, for example in the presence of bundle-branch block. It is usual to describe four standard Splitting of the second sound at the areas for auscultation. Their names do pulmonary area normally increases not represent the surface markings of during inspiration and is easily heard valves but indicate the areas on the in children and young adults. chest wall at which sounds arising in the respective valves are best heard. They are the: (1) Mitral area - the apex Also in children and young adults, a of the heart; (2) Aortic area - the second third heart sound is often present right intercostal space; (3) Pulmonary and is physiological. It occurs during the area - the second left intercostal space; early diastolic filling of the ventricles (4)Tricuspid area- the left lower sternal and is separated from the second border. Auscultation should not be sound by a definite gap. In the presence limited to these areas, but should of heart disease a third heart sound always be performed in these locations may have pathological significance. (using the bell and the diaphragm) as a It is a common finding in heart failure. bare minimum. Attention should be paid Here the combination of an increased to: (1) the ; (2) murmurs heart rate and a loud third sound gives and (3) friction. rise to one form of “gallop rhythm”. A coinciding with It is very important to learn to recognise atrial is also a common cause of the two heart sounds since the position gallop rhythm and is often heard when of murmurs in the is the left ventricle is under strain determined largely by reference as in hypertension or recent myocardial to them. They are most readily infarction. It occurs shortly before the distinguished near the pulmonary area first sound and is to be distinguished and can then be followed by short from splitting of the first sound. steps to other areas such as the apex. Third and fourth sounds are readily recognised when both are present, (1) Heart Sounds but they may be superimposed on The first and second heart sounds one another. In any event in the short should first be identified. Identification diastolic interval of tachycardia it is of these sounds may be made by often far from easy to define the type of relating them to the carotid pulse or “triple rhythm”. to the cardiac impulse at the apex. Attention should then be directed to their quality and intensity. The first sound, at the apex for instance, may be softened when contractility is impaired; whereas it is loud and sharp in mitral stenosis.

25 With the presence of metal prosthetic The radial pulse should not be used vales, prosthetic heart sounds may for this purpose. be heard. These are, unsurprisingly, metallic in quality but differ according (b) Position of maximum intensity – to which valve has been replaced and e.g. mitral or aortic area. the type of valve – bi-leaflet valves typically being quieter than tilting disk (c) Conduction or radiation: the (Bjork-Shiley) vales and than the rare, direction in which the murmur is heard older ball and cage (Starr-Edwards) clearly – for example, to the carotids in vales. The sounds may be heard aortic stenosis, to the axilla for mitral from a distance, and suspected in the regurgitation. presence of thoracotomy scars. (d) Intensity (2) Murmurs This is described as faint, moderate, Murmurs are additional to the heart loud or very loud and may be graded in sounds and result from turbulent blood intensity. flow. They may arise where blood is forced through a narrowed valve orifice (e) Quality or character. or regurgitates through a valve which Various terms are used, among which is incompetent. the most useful are high-pitched or low- pitched, “rumbling”, “harsh” or “rough”, Abnormal communications between “blowing”, or “musical”. the chambers of the heart or great arteries may also give rise to murmurs. (f) Change of murmur with posture Sometimes murmurs, always systolic and during the phases of respiration. in time, may occur in the absence of The more inconstant a murmur, the less any demonstrable structural lesion of likely is it to be significant of structural the heart and are termed “functional”, damage. Sometimes murmurs of “innocent” or “benign”. pathological importance may only be heard after exercise. Murmurs must In listening to and describing a murmur be studied at the bed- side and the the following points must be noted: following incomplete account deals in summary form only with those which (a) Timing the student should aim to recognise Systolic or diastolic. It is this which early in his career gives most trouble to students. Murmurs are best timed by placing their position with respect to the heart sounds, systole being the period between the first and second sound, diastole between second and first sound. The first and second sounds must, of course, have been correctly identified. It may be necessary to use the apex beat or the carotid pulse to time a murmur where cardiac sounds are difficult to distinguish.

26 Diastolic Murmurs • At the aortic area and left border of Diastolic heart murmurs are always sternum pathological. The diastolic murmur of aortic incompetence (aortic regurgitation) is often maximum in the 3rd and 4th • At the apex intercostal spaces at the left sternal The diastolic murmur of mitral stenosis edge. It is an “early” diastolic murmur, is maximum near the apex of the left that is, it follows the second sound ventricle and is poorly conducted. immediately. Low-pitched and rumbling in character, it is best heard with the bell of the stethoscope. Characteristically its It is usually of faint or moderate intensity, of blowing quality and onset is “mid-diastolic”, that is, after a diminuendo. It is relatively high- short interval from the second sound. pitched and therefore best heard Sometimes it is mainly pre-systolic with the diaphragm of the (very late diastolic) and leads up to stethoscope. an accentuated first sound. The pre- systolic accentuation is due to atrial contraction and is absent in atria The patient should be leaning fibrillation. forward and holding the breath in full expiration, a manoevre that should be performed in all patients. These two components of the murmur may be continuous, so that it occupies most of diastole. Sometimes a mitral Systolic Murmurs diastolic murmur may be recognised Systolic murmurs may occupy the only if the patient is exercised and entire systolic interval (pansysytolic) as turned on to the left side. This manoevre in mitral incompetence or VSD, or may should be performed in all patients. be mid-systolic (ejection systolic) as in aortic or pulmonary valve stenosis. The “opening snap” of mitral stenosis best heard just internal to the apex • At the apex (mitral area) beat. It is due to sudden tension in The systolic murmur of mitral the damaged valve as its opening is incompetence (mitral regurgitation) arrested. is conducted to the left axilla and sometimes to the back; is often loud, medium or high- pitched (“blowing”). The first sound is not accentuated and may be soft or absent. It has to be distinguished from benign murmurs which are less loud, less well conducted, blowing or musical in character and often vary with posture. It is often “pansystolic”, being continuous from first sound into the second sound.

27 • At the pulmonary area A loud rough mid-systolic murmur accompanied by a thrill may indicate congenital pulmonary stenosis (rare). Most systolic murmurs here and down the left side of the sternum are benign.

• At the aortic area A loud, low-pitched, rough systolic murmur conducted into the neck (and sometimes accompanied by a thrill) suggests aortic stenosis. It is characteristically mid-systolic (ejection systolic). The second sound is often faint or absent.

The pulse is of poor volume and slow rising character to an extent determined by the degree of stenosis.

The same murmur is commonly heard in elderly patients who have aortic valve sclerosis without narrowing. This is not accompanied by narrow pulse pressure, low volume pulse or radiation of the murmur.

• Friction Pericardial friction is distinguished by its superficial quality i.e. it sounds as if it were nearer to the ear than the heart sounds. It is to and fro and has a coarse “shuffling” quality. The patient should be asked to hold his breath – pericardial friction will not disappear but pleura-pericardial friction may disappear.

28 The Respiratory (4) Sound: normally quiet and barely audible. indicates obstruction System of the upper respiratory tract. Louder sounds may have a “hissing’ quality The respiratory system is examined in “air hunger”, rattling or bubbling in a conventional order. General in pulmonary oedema, wheezing in examination will involve inspection or chronic . of the fingers for clubbing, cigarette tar staining, cyanosis, CO2 retention (5) Uneven movement: the normal (warm hands bounding pulse), T1 chest expands symmetrically. Uneven root wasting, tremour - fine, tremour - movement may result from deformity, axterisitis; also skin, nailbeds, lips and increased “stiffness” of one lung, tongue for cyanosis. The character of pleural thickening or fluid, or narrowing any sputum should be noted, especially of a bronchus. The affected side may the presence of blood (haemoptysis) move less and the other side may or pus. move more than normal.

Inspection Paradoxical movement of the chest Respiratory movement should be usually follows multiple rib fractures. first observed, and the following In this situation the affected flail points noted: segment of the chest wall retract, instead of expanding, during Rate: Normally about 12-18 cycles inspiration. First, stand directly in front a minute at rest. of the patient and look for abnormalities of shape. Repeat from the back The rate is increased in a number and both sides. The normal chest of conditions, e.g. acute pulmonary is symmetrical; note the position of infections, pulmonary thrombo- nipples and whether spinal curvature embolism, heart failure and any is abnormal, i.e. whether kyphosis or condition increasing the work of scoliosis is present. breathing. Palpation (2) Rhythm: usually regular; alternating (1) Position of the trachea: the patient’s periods of apnoea and hyperpnoea chin should be in the midline and (“Cheyne-Stokes” respiration) may the neck slightly extended. Place occur with cerebral disease, e.g. . the index finger in the suprasternal notch and gently feel for the trachea, (3) Depth: increased in conditions which should be central. Note, also, producing metabolic acidosis (air how many fingers can be inserted hunger), for example diabetic coma, between the sternum and the thyroid salicylate poisoning. Decreased cartilage horizontally. This space will (often due to pain) in , fractured normally accommodate two fingers; the ribs and “acute abdomen”, or from space is reduced when the lungs are depression of the respiratory centre hyperinflated in emphysema. by drugs, such as morphine, which also slows the respiratory rate.

29 (2) Note the spacing of the ribs, local (2) Dull or impaired resonance. tenderness, swelling or depression A relatively solid lung-collapse, and the position of the cardiac apex consolidation, fibrosis, thickened chest beat. The neck and axillae should wall or pleura may impair the note. be examined for lymphadenopathy The note is completely dull (“stony (above). dull”) when fluid is present.

(3) The respiratory movements are (3) “Stony” dullness: usually signifies a examined from the front or back by large pleural effusion. laying the hands on each side of the chest symmetrically, stretching the skin (4) Cardiac dullness: is not reliable as with the fingers and with the thumbs a guide to either the size or the position extended to touch each other in the of the heart. midline. The fingers remain fixed on the chest wall and the movement of the (5) Upper border of liver dullness. thumbs reflects chest wall movement. This is often lower than normal (5th Maximum chest expansion may also be interspace) when emphysema is measured with a measuring tape at the present. The lower border of lung nipple line. resonance is found to lie at the 8th rib in the mid-axillary line and at the 10th (4) Tactile vocal . This is a rib posteriorly in the scapular line. classical sign that is probably of little additional value to the detection of Auscultation vocal resonance (below). This should be carried out symmetrically over the whole chest Place one hand on the chest wall while the patient breathes freely and feel for vibration produced when through the open mouth. Compare the the patient pronounces a “resonant” breath sounds on the two sides; slight word, e.g. “ninety-nine” or “one, one, differences are usually not significant one”. Fremitus is usually equal on both sides - pleural effusion abolishes it (1) Breath sounds completely. The normal breath sound heard over the lungs is a murmuring or rustling Percussion sound, heard mainly during inspiration Gives an indication of the condition and at the beginning of expiration of the underlying lung and pleura. - vesicular breathing. This sound is Compare the note over corresponding probably caused by the passage of air areas on each side, either by moving to and fro in small, or even relatively from one side to the other moving from large, bronchi at a distance from the the apex to the base; or examining chest wall, and not by alveolar air each side sequentially. movement, which probably takes place solely by diffusion. Over the trachea (1) Hyper-resonance. When the lung and main bronchi a harsh sound is contains more air than usual, as in heard throughout inspiration and emphysema, or when there is air in the expiration. This sound arises in the pleural cavity, as in pneumothorax. major airways and larynx and is called the bronchial element.

30 Normally the bronchial element is The presence of bronchial breathing is inconspicuous over the lungs but in diagnostic of consolidation, complete certain areas where the trachea and deflation of lung in pneumothorax or main bronchi are near the surface, for cavity formation in the lung. It is usually example the right apical region and accompanied by increased vocal between the scapulae, the bronchial resonance and fremitus. element may be easily detected and the breath sounds are then referred to (2) Voice sounds as bronchovesicular. This is a normal The voice normally resonates through finding. the lungs and can be easily heard through the stethoscope - vocal Abnormalities of breath sounds: resonance. This is examined by asking (a) Diminished breath sounds the patient to repeat “ninety-nine’, occur if there is:(i) a thick chest wall; “one-one--one”, or “one-two-three’, (ii) emphysema; (iii) poor chest while the physician listens over movement due, for example, to pain comparable areas on the two sides of on respiration; (iv) fluid or air in the the chest. Increased vocal resonance pleural cavity, also pleural thickening; indicates consolidation or cavity (v) collapse of lung tissue formation - when even the whispered voice is transmitted, it is referred to as (b) Increased breath sounds may be “whispering ”. heard through a thin chest wall, or if the patient is over-breathing. Increase (Note again the association between in the intensity of the breath sounds bronchial breathing, whispering is unimportant unless there is also an pectoriloquy and increased tactile vocal alteration in the quality of the sounds. fremitus). Decreased vocal resonance is most often due to fluid in the pleural (c) Alterations in the quality of the cavity, to reduced ventilation of a part breath sounds: where there is airway of the lung (for example, bronchial narrowing, such as in bronchitis narrowing from a tumour) or to pleural and asthma, the expiratory phase of thickening. Sometimes at the upper vesicular breathing is prolonged. limit of a pleural effusion the voice An important qualitative alteration in the sounds have a bleating quality — breath sounds is bronchial breathing. aegophony. In this, the bronchial element of the breath sounds is conducted to the (3) Adventitious sounds Adventitious periphery of the lung with abolition sounds may be heard, in addition to of the normal vesicular element. The normal breath sounds. sound is quite distinctive and must be learned by practice.

Its characteristics are a harsh resonant quality; equality in length of the sounds heard during inspiration and expiration; the expiratory sound has the same or higher pitch than the inspiratory sound; a distinct pause between the sounds heard during inspiration and expiration.

31 These are: (c) Pleural friction rub A constant to and fro noise, i.e. (a) Wheeze (rhonchi) heard in both inspiration and expiration, These are due to narrowing of the due to the rubbing together of the bronchi from obstruction by secretion inflamed parietal and visceral pleura. of mucus or by congestion. They are It is distinguished by its “to and fro” predominantly wheezing expiratory character and by the fact that it is sounds and may be subdivided into heard superficially (i.e. close to the low-pitched rhonchi and high-pitched end of the stethoscope). In quality it (sibilant) rhonchi, the differences in may be loud and creaking and then it tone reflecting the size of the affected may be palpable as a friction fremitus, airways. or fine and crackling, when it may be difficult to distinguish from coarse (b) Crepitations crepitations. Friction is always best Interrupted high-pitched crackling heard where movement of the lungs sounds, which may be due to is greatest and is most often detected opening of alveoli and small airways. at the bases laterally or posteriorly. They are heard predominantly at the It is usually, but not always, associated end of inspiration and may be altered with characteristic pleuritic pain and by coughing. When they arise in the is usually loudest over the site of bronchi, they are coarse and the pain. bubbling in character and are heard in both inspiration and expiration. Fine crepitations arise in the periphery of the lung and are heard most often at the lung bases. They are heard mainly at the end of inspiration and may be caused by fluid or fibrosis.

32 The Abdominal (3) Movement of the abdomen. Normally the abdomen moves freely Systems (GIS, GUS with respiration. The extent of this and Haematological) movement depends upon the type of respiration and is greatest in patients Examination of the Abdomen whose respiration is predominantly Follows the conventional order – diaphragmatic rather than intercostal. inspection, palpation, percussion and auscultation: Excessive abdominal movement is seen when the abdominal muscles are used Inspection as accessory muscles of respiration. Diminished or absent respiratory (1) The general contour of the abdomen. movement is associated with an Generalised enlargement may be due inflammatory lesion in the peritoneal to obesity, to distension of the intestines cavity e.g. perforation. with either gas or faeces, to the presence of fluid in the peritoneal cavity (ascites) or to pregnancy (the 5Fs). New (4) Pulsation. The abdominal aorta may eversion of the umbilicus may indicate be seen pulsating in the epigastrium that the distension is due to some especially in thin, normal subjects. pathological cause. Asymmetrical or Other causes of epigastric pulsation localized enlargement of the abdomen is are transmitted pulsation from the caused by enlargement of a viscus, e.g. right ventricle, dilated or aneurysmal liver, spleen, stomach, pregnant uterus. dilatation of aorta or a pulsating liver in tricuspid incompetence. Retraction of the abdomen (the opposite of enlargement) is seen in emaciated (5) Peristalsis. Visible peristaltic patients and due to severe dehydration. movements may be seen in thin, emaciated subjects, but if (2) The appearance of the skin. accompanied by distension and The skin may be wrinkled, shiny, moving predominantly in one direction, suggest obstruction. In pyloric stenosis, tense or oedematous. Scars of previous the stomach is distended in the left abdominal operations and striae upper abdomen and peristaltic waves indicative of in are seen passing from left to right. the past should be noted. Pigmentation Conversely, in obstruction of the either localised or generalised may be transverse or descending colon, the present. The presence and distribution peristalsis crosses the upper abdomen of hair is important in endocrine from right to left. In small bowel disorders. Sparseness or absence obstruction the distended coils of axillary and pubic hair occurs in of intestine form a “ladder” pattern in pituitary deficiency, and in the elderly. the centre of the abdomen. When there is obstruction to the portal vein or inferior vena cava, dilated tortuous veins may be present over the Palpation abdominal wall and the direction of flow The technique of abdominal palpation in these should be determined. Spider varies, depending on the purpose naevi occur in the skin area above the for which it is employed. If possible, nipple line in chronic liver diseases. remove all pillows but one, so that the patient is lying flat.

33 The examiner should, if possible, sit or (b) Palpation for enlargement of kneel by the bedside when palpating specific organs. Attempt to feel the liver, the abdomen. For most purposes spleen and kidneys in turn. The liver is the warm hand is placed flat on the sometimes just palpable in health and abdomen but sometimes when fluid is may appear enlarged in emphysema present it is necessary to “ballot” for as it is pushed downwards by the over- organs using the pulp of the fingers. distended lungs.

(a) General palpation. It is usual to (1) Liver. It is essential to start in the begin by palpating gently each of the right iliac fossa, lateral to the lateral four quadrants of the abdomen, any border of the rectus muscle (to avoid area of suspected tenderness being the tendinous intersections) and to examined last. This helps to gain the work upwards with the fingers dipping, patient’s confidence and will also so as to detect the edge of the liver determine the presence or absence of while the patient takes deep breaths. any marked guarding The liver moves with respiration. If the or rigidity of the abdominal wall and liver is felt, note: (i) that it moves on areas of tenderness. It will reveal any respiration; (ii) if it has a sharp edge; gross swellings or enlarged viscera. (iii) its consistency; (iv) firm or soft; Deeper palpation can then be used to (v) the presence of irregularities on supplement the information already its surface and edge, and if present, gained. Try and determine the shape, whether smooth or irregular; (vi) if it is size, nature, consistency, degree of tender - the liver is tender if inflamed movement and mobility of any mass (hepatitis) or if it is congested (as which can be felt. in heart failure); (vi) the degree of enlargement which may be recorded Note whether it is tender or not. in centimetres or inches from its lowest The commonest palpable pathological level to the costal margin swellings are the enlarged liver, spleen in the right mid-clavicular line; or kidney, for which special techniques of palpation are used (see below). (vii) the presence or absence Other palpable pathological swellings of pulsation (found in tricuspid are enlarged urinary bladder or gall- incompetence); (viii) confirm findings bladder, and tumours of the stomach on percussion. or colon. In the left iliac fossa the descending colon is often palpable, (2) Spleen. The spleen cannot normally either because it is filled with faeces be felt, since it must be 2-3 times (constipation) or because it is spastic. enlarged before it is palpable. Begin Learn to recognise the feel of the low down on the right side of the normal abdomen which varies greatly in abdomen, moving up towards the left different individuals and to distinguish upper quadrant. The spleen is more the difference between abdominal easily felt if the other hand is placed in muscles especially the rectus muscles the left loin to afford counter pressure. and palpable viscera or swellings. The spleen is relatively superficial. It moves with respiration.

34 If it is palpable, note: (i) its size (i) that it moves with respiration; recorded in centimetres below left (ii) if it has a rounded lower margin; costal margin; (ii) the direction of (iii) that the right (lower) kidney can enlargement; the spleen usually be palpated in many normal thin enlarges downwards, medially and individuals, but that a palpable left anteriorly, towards the umbilicus; kidney always means pathological (iii) its consistency – hard, firm, enlargement; (iv) that, if considerably soft; (iv) the presence of the splenic enlarged, may be dull to percussion, notch- which is sometimes felt in large but that the left kidney is crossed by spleens and which is diagnostic of a band of resonance due to adherent ; (v) if it is tender; overlying colon (in contrast to the (vi) if the fingers can be inserted spleen). between its upper margin and the left costal margin (“One cannot get above (4) Uterus and Bladder. These may the spleen”and this helps be felt centrally, usually in the lower to differentiate the spleen from an abdomen, the uterus when gravid enlarged left kidney); (vii) if the fingers or diseased and the bladder when can be inserted between the posterior abnormally distended. Percussion margin and the paraspinal muscles, from the umbilicus to the pelvic brim with the patient lying on his right side will help confirm. (“One can get behind the spleen” , again differentiating spleen from (5) Palpation for fluid thrill. This is kidney); and (viii) on percussion of confirmatory of ascites but when it is enlarged spleen there is no overlying elicited the presence of free fluid is band of resonance (unlike the rarely in doubt. The thrill is generated kidney). If there is doubt about splenic by tapping one flank and feeling the enlargement, palpate the spleen with thrill with the flat of the hand in the the patient on their right side. This opposing flank. To restrict cutaneous manoeuvre often allows a questionably transmission, it is necessary to place a enlarged spleen to present its edge hand vertically, in the midline – this is more easily. usually provided by an assistant, or the patient. (3) Kidneys. Use bimanual palpation. As with spleen, insert left hand into Percussion renal angle posteriorly applying Percussion may be used to confirm pressure upwards. With right hand, the enlargement of the liver and spleen. start to palpate low in iliac fossa, Light percussion is used. A band of applying pressure upwards and resonance crosses the enlarged downwards, asking the patient to kidney but not the enlarged spleen. breathe deeply. Alternatively, apply The distended bladder is dull to constant pressure from the top hand percussion. Percussion is also used and intermittent pressure from the to elicit , which is the underlying hand – “pushing” the kidney most valuable evidence of ascites. towards the top hand. A palpable or The abdomen is percussed outwards enlarged kidney will be felt between from the umbilicus and if fluid is the tips of the fingers of the opposed present, the flanks will be found to be hands. If the kidney is palpable, note: dull to percussion.

35 The extent of the dullness can be marked and shown to recede daily, Rectal examination should not be if the amount of fluid is diminishing. omitted in a patient complaining of symptoms referrable to the alimentary To confirm the presence of fluid, the system, or in those who have passed patient should be laid on one side so blood per rectum. The procedure that one flank is uppermost, when it will should be explained carefully to the be found that the dullness has shifted patient and undertaken with great care and the flank is resonant to percussion. in patients with anal pain. The patient Note that, in gross hepatic or splenic is laid on the left side with the knees enlargement, the flank may remain flexed and asked to breathe quietly dull to percussion, as it is still filled by and relax. The examining finger should the enlarged viscus. Accompanying be protected by a well lubricated physical signs of ascites are eversion finger stall or glove. Initially, gently and a crescentic shape of the umbilicus separate the buttocks and examine the and the presence of a fluid thrill. external anal appearances for external haemorrhoids, fissures, openings of Auscultation fistulous tracts, perianal abscesses Normally, intestinal movements give and the purplish indolent undermined rise to sounds known as borborygmi. ulcers that are seen in some patients When is present, sounds are with Crohn’s disease. The index finger often absent; when there is intestinal is then gently inserted and palpation obstruction, they may be exaggerated, performed all round the rectum. explosive and at a higher pitch than Note: (i) if rectum is full or empty with normal. In pyloric obstruction splashing faeces; (ii) whether it is contracted sounds may sometimes be elicited or dilated; (iii) recognise the normal over the stomach if the patient is gently feel of the prostate in males and the moved from side to side (heard without cervix in females; (iv) record any other using the stethoscope). abnormality such as the presence of an anal ulcer or carcinoma; (v) when the Examination of the groin and genitalia. examining finger is withdrawn, examine Routine inspection and palpation of its surface for blood, mucus, the colour the groin for swellings due to herniae, of the stools. lymph nodes, and abnormal vessels should be carried out. When a Where appropriate, test a smear of is suspected, the patient should be faeces for occult blood. Note that a examined in a standing position. complete examination of the alimentary Examination of the female genitalia system involves inspection of the is not routinely carried out unless tongue, teeth, mouth and throat, and there is a specific indication. In these examination for jaundice, anaemia and circumstances a chaperone should other signs which are dealt with under be present. the general examination section.

36 The Nervous System (2) Note patient’s appearance and behaviour. Is he apathetic, agitated or depressed? Does their attention To examine the nervous system wander? Are they unkempt? Are properly, a working knowledge of the their replies to questions sensible, anatomy and physiology of the central reasoned? nervous system is essential. The history and signs assist in localising the site (3) Do they have any delusions or (or sites) of the lesion (or lesions). hallucinations? A diagnosis is arrived at, primarily by considering the temporal course of the (4) Are there signs of memory loss – illness but the localisation may suggest simple assessments including name, the nature of the disorder in address, age, DOB, current events, some instances. A detailed examination recent events. should direct appropriate investigations. There are five main components of the nervous system: (1) the higher cerebral (5) Speech: distinguish between: functions; (2) the cranial nerves; (a) Dysphasia - inability to find words (3) the motor system; (4) the sensory for speech or writing (motor) or to system; (5) the autonomic system. understand them (sensory). Sometimes both types are present. Results from damage to the speech areas of cortex. Higher cerebral function (b) dysarthria - interference with (1) Estimate the level of consciousness: motor act of speaking (lower cerebral, (a) fully conscious; cerebellar or peripheral). (b) properly orientated in time and It may be convenient at this point to test space; for signs of meningeal irritation, which (c) able to answer simple questions; does not fit neatly into any other section (d) responds to commands; of neurological assessment: (e) responds to painful stimuli; (i) neck stiffness; (ii) Kernig’s sign; (f) coma; (iii) Brudzinski’s sign. (g) pupillary response to light, absent; (h) control of respiration and vasomotor reflexes impaired.

Note: there are formal assessments that may be appropriate to specific situations – for example, in the critically ill patient or in the confused patient, it is appropriate to make an assessment of conscious level or memory using a standard instrument, such as the Glasgow Coma Scale, or a Mini Mental State examination. These are not covered here.

37 Cranial Nerves (ii) Note the appearance of the retinal It is convenient to go through these arteries and veins. In healthy young in numerical order. adults, the arterial wall is not normally visible; what is seen is the column I. Olfactory Nerve of blood. In older patients, a certain degree of fibrosis, which gives a “silver This is rarely tested in clinical wire” appearance to the arteries, is practice. Test each nostril separately normal. Veins are normally darker in - use oranges, coffee, or other well appearance than the arteries and the recognised odours individually. Note normal ratio of width of vein to width any anosmia (loss of sense of of artery is 2:1 or 3:1. An estimation of smell). Ask the patient about alterations the arterial wall may be made at in sense of smell and taste. arterio- venous crossings. This is accentuated in hypertension giving II. Optic Nerve the appearance of “nipping”. (a) Test acuity of vision in each eye separately (cover with hand) using (iii) The general state of the eyegrounds a Snellen Chart or available written should be observed and the presence material. Can patient see? How much of any haemorrhages or exudates, can they see? described as ‘hard, white or cotton wool’, noted. Perception of light; recognition of moving objects; ability to count fingers; (d) Pupils ability to read large type (newspaper headlines); ability to read small type Note: (i) Position, size and shape; (ordinary newsprint).If there is a defect, (ii) equal or unequal; (iii) regular can it be corrected by spectacles? or irregular; (iv) reaction, directly and consensually, to light and on convergence. (b) Fields of vision - confrontation method. Check each eye independently. III, IV, VI. Oculomotor, Trochlear, and Abducens (c) Fundi Nerves Test full range of movements, for gaze (i) Examine the optic discs, learn to fixed on distant objects as well as on a recognise the appearance of the normal near object. Test the eye movements optic disc and be able to appreciate by asking the patient to follow your gross changes, such as the pallor of finger in a fixed pattern, that tests up primary optic atrophy and marked and down, with the eyes abducted and swelling of the disc (papilloedema) as adducted, as well as in the midline. seen in increased intracranial pressure It is very important to keep a reasonable and accelerated hypertension. distance (around 1 metre) from the patient and to test the eye movements slowly and deliberately.

38 Do the ocular axes remain parallel or VIII. Auditory do squint and double vision (diplopia) (1) Cochlear develop? Look for . Keep If the patient wears a -aid, test object at a comfortable distance remove it first. Test hearing in each ear and within the field for binocular vision. separately by whispering numbers, with Do not expect diplopia at the extreme the other ear closed. Distinguish nerve periphery of the visual fields, which is (perception) deafness from middle-ear normally monocular; indeed nystagmoid (conduction) deafness by the following jerks may occur in normal subjects on two tests: (i) Rinne’s test - a vibrating extreme deviation of gaze. Note any tuning-fork is held on the mastoid drooping of upper eyelids (ptosis). process until the sound disappears, and is then removed to in front of the V. Trigeminal Nerve ear. If the sound is heard again (as it is Sensory Division: Test using cotton normally), it indicates nerve deafness. If wool and blunted sterile pin over the sound not heard again, middle- three areas supplied. The testing of the ear deafness. (ii) Weber’s test - the corneal reflex is potentially dangerous tuning-fork is held on the middle of and is not routinely done, but only the patient’s forehead. If the sound is when the history suggests a possible referred to the good ear it indicates involvement of V or when the other nerve deafness on the other side. cranial nerves VI and VIII are involved, If referred to the deaf ear it indicates but V is apparently spared. Motor middle-ear deafness (because there is Division: Ask patient to open mouth less masking by other sounds). (note any deviation of mandible). Test strength of opening and closing mouth (2) Vestibular portion concerned with by counter pressure on the lower jaw. balance: lesions may produce vertigo and nystagmus. Usually tested by VII. Facial Nerve caloric tests - not done at bedside. Is the face symmetrical at rest? Test movements of upper face: (i) wrinkle IX, X. Glossopharyngeal and brow; (ii) close eyelids tightly; (iii) test Vagus Nerves movements of lower face; Ask patient to say “Ah” and watch (iv) show teeth; (v) whistle. palatal movement. The palate should rise well and in the midline. If there is a difference between the two sides? Is this more obvious in the lower Note: hoarseness may result from a face? Note any difference between vagal lesion but examination requires expressive movements and volitional laryngoscopy. movements. XI. Accessory Nerve In an upper motor neurone palsy, the Test trapezius - shrug shoulders paralysis is more obvious in the lower against resistance. Test Sternomastoid half of the face and volitional movement is more affected than expressive – turn chin against resistance. movement. In a lower motor neurone palsy, the whole of the affected side of the face is paralysed for both types of movement.

39 XII. Hypoglossal Nerve (3) Power- first make sure that the Ask patient to stick tongue out and patient has no gross paralysis, (e.g. move from side to side. Check for hemiplegia which prevents complete wasting and any . movement of a limb). Then test ability Examination of the limbs and trunk. to make active movements at each This should be done systematically. joint by getting the patient to carry out Compare arm with arm, leg with movements against resistance and leg, making allowances for patient’s compare with the opposite side. “handedness”. It is usually preferable As you test each movement think of: to finish the examination of the arms (a) which muscle you are testing before proceeding to the legs. (b) which nerve you are testing The examination follows the order: (c) which spinal segments you are (i) inspection; (ii) movements – power; testing (e.g. Flexion of (iii) tone; (iv) co-ordination; (v) reflexes – (a) biceps and brachialis; (b) and (vi) sensation. The precise musculocutaneous nerve; (c) C6. sequence is less important than remembering to cover all the sections (4) Co-ordination. Perfect co- – tone can come before movements, ordination, ability to maintain posture if it suits better. and precision of voluntary movement requires not only an intact motor (1) Inspection - rhythmical tremor; fast system but also an intact afferent or slow; ; chorea; myoclonic supply from the muscles and joints. jerks, wasting; fasciculation (muscle When testing co-ordination, therefore, twitching). Deformities - wrist drop; it is important to ask the patient to foot drop, contractures. These indicate carry out the tests, first with their eyes imbalance of antagonistic muscles. open and then closed, and to note Note any asymmetry or atrophy. any difference. If co-ordination is due to a motor disturbance then closing (2) Tone (passive movements) - put the eyes makes no difference (motor each joint through a full range of or cerebellar ); if it is due to passive movements. Learn to recognise interference with the afferent pathway the normal degree of the incoordination is worse when resistance to passive movement and to the eyes are closed (). appreciate increased resistance, due Can they perform the following tests accurately? (i) Finger to nose; to increased muscle tone. Is increased resistance to passive movement (ii) finger to finger; (iii) heel to knee present throughout the whole range of and then along the anterior border movement (“cogwheel rigidity”) as in of tibia to great toe; (iv) can they extrapyramidal lesions, or only initially walk heel to toe (tandem gait)?; (v) (“claspknife spasticity”) as in pyramidal is there any loss of rapid alternation lesions? of movement (dysdiadokokinesia)?; (vi) can they stand steady at attention with eyes closed or do they tend to Decreased resistance due to loss of sway (Romberg’s sign)?; (vii) tap the muscle tone is flaccidity. Remember patient’s outstretched arms. Do they that limitation of movement may also return promptly to the same position be due to a primary lesion in the joint or without excessive oscillation? to organic shortening (contracture) of muscles.

40 (5) Reflexes If any defect of one of these modalities Tendon Reflexes is found, the boundaries of the affected Upper limb: (i) biceps (C6); area should be mapped. Start from (ii) triceps (C7); (iii) brachioradialis within the area found to be insensitive (“supinator” C6). Lower limb: (i) knee and move stimulus radially to define the (L3,4); (ii) ankle (S1). borders of the insensitive area.

If the reflexes are brisk, tap more gently (ii) Deep sensation to get some indication of the reflex (a) Vibration sense - ability to “threshold” with respect to normal and appreciate the vibration of a large (128 test for clonus. This must be sustained c/s) tuning fork applied over the bony for several beats before it is significant. prominences. Superficial Reflexes: (i) abdominals; (ii) cremasteric; (iii) plantar – response – (b) Appreciation of passive movement - flexor or extensor (Babinski’s sign). ability to recognise which digit is being In recording the results, the following moved and to appreciate the direction symbols may be used: 0 - absent; of movement (proprioceptive sensation) 1- present, diminished; 2 - normal; (c) Deep pressure pain - firm pressure 3 –exaggerated; 4 – clonic. on the Achilles tendon is normally painful. This is not assessed routinely. (6) Sensation The testing of sensation is the least (iii) Stereognosis objective part of the examination of The ability to recognise objects by the nervous system. It requires time touch, appreciation of weight and and patience on the part of both the texture. It is important only in cerebral examiner and the patient, but slow lesions and only then if peripheral meticulous testing of all surface areas touch, muscle and joint sense are is tiring and confusing to the patient. present. The results are sometimes difficult to interpret. For ordinary purposes the It is tested for by asking the patient to following should be tested rapidly recognise, with the eyes closed, objects in representative areas, comparing placed in his hand or to recognise one side with the other. It is useful to numbers drawn on his palm. consider the distribution of spinal roots and peripheral nerves when performing Autonomic nervous system these tests. Areas of sensory loss Note any disturbance of vasomotor revealed in this way may then be activity especially in the extremities, mapped more systematically. The most e.g. any cyanosis, pallor or difference sensitive test for loss of cutaneous in temperature and any nutritional sensation is ability to recognise two changes in the parts. On the whole, points of a compass. such changes are more often due to (i) Cutaneous sensation peripheral than to (a) Light touch interference with the autonomic nervous (b) Pinprick (not pain) system. (c) Temperature. Note any increase or decrease in the amount of sweating.

41 Sphincters Information about these is obtained mainly from the history e.g incontinence or precipitancy of micturition but the tone of the anal sphincter can be determined by rectal examination (see earlier).

42 History & Examination • work capacity • history of drug therapy – especially in Joint Disease side effects and • family history e.g. haemophilia, An accurate diagnosis is essential in gout the care of a patient with joint disease. • social history Not only must the joints be examined, but a complete and comprehensive Physical Examination history and clinical examination of the Particular attention should be paid to patient is mandatory, since joint disease the following - is frequently a manifestation of an • general appearance, including underlying systemic disease. The posture and gait detailed examination of individual • skin lesions joints is best learned at the bedside. • psoriasis What follows, therefore, are some • lupus erythematosus (LE) general guidelines: • erythema nodosum • scleroderma History • subcutaneous nodules The following should be specifically • tophi noted: • lymphadenopathy • preceding illness or possible • ocular lesions (associated with precipitating factors, including local some joint diseases) injury, either recent or in the past • hepatomegaly (e.g Felty’s • recent urogenital disease syndrome) e.g.urethritis and recent eye disorders, e.g. uveitis Joint Examination date and mode of onset of joint The student should learn to recognise symptoms the important physical signs of joint • description of complaint disease, which include: • pain • skin colour • stiffness • temperature • mechanical dysfunction • scars of previous sepsis or • nature and pattern of subsequent • joint swelling progression • periarticular swelling • noting factors which alleviate or • synovial hypertrophy exacerbate symptoms • effusion • presence of constitutional features • bony enlargements due to (weight loss, rashes, etc.) osteophytes • duration and severity of morning • presence of nodules stiffness • gouty tophi • degree of functional impairment in • joint tenderness, localised or terms of normal activities diffuse (not excluded unless • walking distances firm pressure applied to joint); • climbing stairs if localized, relate to • ability to put on shoes knowledge of underlying anatomy

43 • joint crepitation - fine “rubbing” Examination of the Urine crepitation in rheumatoid joints, Examination of the urine is essential. coarse “grating” or “grinding” in This is usually performed using osteoarthritis DIPSTIX. • joint deformities – may be fixed or • Glycosuria usually (but not always) postural indicates diabetes. • result from muscle imbalance, joint • Proteinuria may be due to urinary contractures, subluxation or tract infection (and the urine should dislocation be examined microscopically • joint mobility - limited or excessive for pus cells) but may indicate • test and record active and passive other primary renal disease. range in normal plane then check If present, proteinuria should be for abnormal mobility in other quantified by measuring the planes protein/creatinine ratio. • muscle changes • Haematuria – may be associated • weakness with at any level of the • atrophy urinary tract. Microscopy for casts • shortening is essential if glomerulonephritis is • tendons suspected. • synovial hypertrophy • presence of nodules Note: a joint which has a free range of pain-free movement is unlikely to have much wrong with it.

44 Examination of the Physical Examination Examination of the skin and mucous Patient with a Skin membranes. Unless the presenting Complaint complaint is clearly localised (e.g. warts), the patient should be examined History fully undressed, on an examination Skin and mucous membranes: couch, in a good light, preferably 1. Duration of complaint and site first daylight. affected. (This is often not the site Note: which is maximally involved when (1) The distribution of the eruption. the patient is seen as an inpatient or • Is it mainly on extensor surfaces of outpatient.) limbs or on the flexures? 2. Course of complaint: • Are body folds involved? • steady deterioration or • Are there scalp or nail lesions? exacerbation and remissions • Does the distribution suggest light • are other family members affected? sensitivity (face, hands and V of 3. Relationship of complaint to: neck)? • occupation • Never forget to examine the oral • leisure activities mucous membranes. • exposure to sunlight, oil, detergents, • Does the distribution suggest epoxy resin adhesive, an external irritant (footwear or photographic chemicals spectacles)? 4. Previous treatment for this disorder: (2) The individual components of the • topical corticosteroid preparations skin eruption. can grossly change the • Are they macular, as in , appearance of many dermatoses papular or pustular, as in acne? 5. Current drug therapy including: • Are there raised weals (urticaria) • laxatives, hypnotics, analgesics or firm nodules (tumours)? • contraceptives • The presence of blisters,vesicles, 6. Past history of cutaneous ulceration or atrophy should always problems. be noted when present. 7. Family history of cutaneous • Scars and lichenification (thickened problems. skin with increased markings) 8. The patient’s own views on the suggests a chronic, long-standing aetiology of his problem. problem. • Excoriations indicate active Pruritus

45 Summary Plan for (3) GI System • Appetite Taking History and • Weight loss Physical Examination • Dysphagia in the Adult • Nausea • Vomiting • Abdominal Pain Presenting symptom(s) • Nocturnal Pain • (Patient’s own words) • Belching Duration of symptom(s) • Flatulence History of presenting complaint(s) • Flatus Systematic Enquiry • Reflux • Water brash Past : • Heartburn • Illness • Constipation • Operations • Diarrhoea • Injuries • Jaundice • Allergies

(4) Haemopoietic System Family History • Sore tongue Drug History • Blood loss Social and Personal history • Pallor • Bruising (1) CVS • Symptoms of anaemia • Breathlessness • Chest pain (5) CNS • Ankle swelling • Loss of consciousness • Palpitations • Mental state - memory etc • Dizziness • Weakness or paralysis of limbs • Fainting • Faintness • Pain in calves • Numbness • Rest pain coldness of feet • Loss of sensation • Dead fingers and toes • Giddiness • Visual disturbance (2) Respiratory System • Tremor • Cough • Tinnitus • Sputum • Sphincters • Haemoptysis • Speech • Breathlessness • • Hoarsness • Depression • Sore throat • Nasal discharge • Epistaxis • Wheezing • Smoker

46 (6) GU System • Frequency • Retention • Dribbling • Dysuria • Loin Pain • Swelling of face • Generalised oedema • Menstruation • Prolapse • Dyspareunia • Incontinence • Impotence • Urethral discharge • Prostatitis

(7) Endocrine System • Polyuria • Thirst • Temperature preference • Sweating • Flushes • Tremor • Neck swelling • Libido • Hair

(8) Locomotor System and Joints • Joint Swelling • Pain • Stiffness • Previous injury • Mechanical dysfunction

(9) Skin • Occupation • Exposure to irritants, drugs, sunlight • Rashes • Pigmentation

47 Percussion: organ size and position. Physical Examination Auscultation: and bowel sounds. Examination of groin and genitalia: General Examination – anaemia, Rectal Examination: jaundice, temperature, lymphadenopathy, clubbing etc. Examine also – head, eyes, nose, Nervous System mouth, neck, breast and hands Higher cerebral functions – Cardiovascular consciousness, memory etc.

System Cranial Nerves: Motor System: – wasting, fasciculation; power, tone; Pulse: rate, rhythm, volume, character, co- ordination; reflexes and sensation. condition of vessel wall, blood pressure, peripheral pulses, JVP, arterial bruits, Cutaneous sensation – touch, pain oedema. (temperature).

Examination of heart: inspection, Deep sensation - proprioception, palpation - apex beat, thrills, right vibration, (deep pressure). ventricular heave. Stereognosis Auscultation: heart sounds, murmurs, pericardial friction Locomotor system

Respiratory System Examination of joints: inspection, palpation, range of active and passive Inspection: respiratory movement – movements, stability. rate, rhythm, depth, sound, uneven movement, shape of chest. Skin Palpation: position of trachea and apex beat, respiratory movements, tactile Inspection, palpation description of distribution of rashes, lesions. vocal fremitus, lymphadenopathy. Percussion: Auscultation: breath Urinalysis sounds, voice sounds, adventitious sounds, wheeze (rhonchi), crepitations, Record dipstix urinalysis and pleural friction rub. microscopy (if performed).

Alimentary System Summary

Inspection: contour, movement, The summary should include a short pulsation, peristalsis. narrative of the key points in the history and examination fields Palpation: tenderness, rigidity, liver, • Differential Diagnosis spleen, kidneys, masses, ascites • Plan of Investigation (fluid thrill). • Treatment Plan

48 Special Systems Obstetrics 1. Date of LMP 2. Date (if known) of positive History Taking in pregnancy test Obstetrics and 3. What (if any) confirmatorytests of gestational age (e.g. ultrasound) Gynaecology 4. Prenatal screening tests (e.g. AFP) When and whether In addition to the components of a performed/ declined and results general history and examination, 5. Fetal movements there are specific sections in a 6. History of past pregnancies to gynaecological history and in an include for each: obstetric history which should be highlighted: Date Gynaecology Outcome 1. Parity (usually recorded in the form para x+y, where x represents the Gestation at end of pregnancy number of completed pregnancies and y the number of incomplete Mode of delivery – SVD, MCFD, LUSCS pregnancies (e.g. )). 2. The date the last menstrual period etc. (LMP) commenced. 3. The usual menstrual cycle; Sex, weight and status of baby frequency, and duration of bleeding (e.g. 5/28 days). Documentation of Mode of feeding the volume of blood loss and the presence of blood clots, use of sanitary Current information on child towels/tampons, the number used and changing pattern of use. Complications of pregnancy e.g. 4. Intermenstrual bleeding (IMB) pre- eclampsia 5. Post coital bleeding (PCB) 6. Painful periods - dysmenorrhoea Information on the mode of conception 7. Pain on intercourse – dyspareunia (if assisted conception) 8. Contraceptive history 9. Cervical smear history and results Information on the father of the child 10. Previous gynaecological (e.g. if pre-eclampsia in previous procedures pregnancies) 11. Examination – use of a named chaperone where appropriate 12. Examination – pelvic and vaginal examination

49 History and Physical From the age of three years this may be tested more effectively by formal Examination of the intelligence tests. Infant and Child Examination Infants and children are not mini-adults Before dealing with details there are and require special knowledge, both in some broad principles which differ from taking a history and in examination. examination of adult patients.

History Pre-school children may be unco- The basic form of the history is not operative, easily frightened or negative. dissimilar to that of the adult but since For many reasons the first examination inherited, congenital and familial is very important because this may problems play a greater part much determine the child’s attitude to further more emphasis is placed on recording examination. Here are some basic such things as: precepts.

(a) The family history of the child’s (a) Unhurried observation of a mother siblings, parents, grandparents and and child entering the room and the other close relatives. latter undressing may be very helpful. (b) The social background. Are (b) Time spent making friends with the the parents married, are they living mother and child may be amply repaid together, are all the siblings born in co-operation. of the same parents? Is the home (c) Sit down beside the child in bed and impoverished, do not tower unnecessarily over her. over-crowded or insanitary? (d) At all possible times chat to the child (c) The obstetric history of the mother, about her food, her doll or any other including all previous pregnancies suitable toy; silence is frightening. and their outcome; and the ingestion (e) Begin your examination slowly and of drugs, infections or other incidents carefully. Carry out the most important, during the first trimester (when the painless tests before proceeding to foetus is developing) of the relevant signs with little relevance or productive pregnancy. Details of delivery are of discomfort or pain. recorded. (f) Cold manners, instruments, hands, (d) A detailed feeding history for young rooms and patients are all undesirable. children and infants. This includes type (g) Remember the safety of young and volume of milk daily, amount of patients. Do not leave open safety pins supplementation, introduction within reach, do not leave cot sides of gluten-containing cereals and so on. down and do not under-estimate the (e) Details of immunising and speed and mobility of young children! vaccinating procedures, infections which have occurred and recent contact with infectious disease. (f) A record of the child’s psychomotor development, which is initially mainly a test of developing motor function.

50 New-born Some problems cannot be foreseen but It is important that all new-born infants abnormal behaviour alerts suspicion: are examined at least twice within the first week of life. • vomiting • lethargy Apart from a brief inspection • food refusal immediately following birth, they should • convulsions be carefully examined within a few • haemorrhage hours of birth, and at one week. Since • delayed passage or urine or most are now born in hospital, this meconium second examination is generally made • pallor, cyanosis or jaundice on the day prior to discharge. New-born • tachypnoea or other disorders of cannot communicate their complaints. respiration • excessive weight gain or loss It is essential to become familiar with the normal pattern of behaviour in infants – only then can deviations from Inspection at Birth normality be detected. The “history” Note whether the baby is breathing remains vitally important but has to at all and if so the respiratory pattern. be obtained from the mother herself, Note whether the baby is cyanosed or from her obstetric notes, or from not. The heart note is counted and the observations made and recorded by motor tone and response to stimuli are the nursing staff. noted. From these an assessment of the new-born is made (). The vast majority of new-born do Obvious developmental abnormalities perfectly well, but some suffer from such as meningomyelocele and disease which is either congenital hydrocephalus and extroversion of or acquired in utero. It is frequently bladder are noted. As assessment of possible to predict before birth an “at- the maturity (gestational age) of the risk infant” who should be admitted to new-born is made from size, general an observation nursery following birth. appearance and reference to skin, nipple size and character of external genitalia. The number of umbilical Some predictable problems: arteries is recorded.

• premature labour • known placental insufficiency • hydramnios or oligohydramnios • rhesus iso-immunisation • multiple births • maternal diseases such as – diabetes • mellitus, thyrotoxicosis • instrumental deliveries • birth

51 First Examination (1-4 hours old) The rapid heart rate makes sounds The weight and head circumference is and murmurs difficult to interpret to recorded. The baby is systematically the untutored ear. The abdomen is examined for developmental inspected, palpated and percussed. abnormalities such as extra digits, The mouth is inspected for cleft webbing of fingers or neck, Down’s palate and the patency of the anus syndrome, abnormality of head shape, determined. Particular care is taken to abnormal facies (as in renal agenesis), exclude jaundice which, in haemangioma, pigmented naevus, the early hours of life, is usually due spina bifida and a host of others. to severe haemolysis. The bladder should be palpated and if large, Conditions acquired in utero such as suggests posterior urethral obstruction. talipes equinovarus (club foot) are Abnormalities of genitalia, such as noted and perinatal damage such as hypospadias, intersex or undescended cephalhaematoma or brachial plexus testes should be noted. injury or rarely fracture of clavicle or of a limb. Evidence of dysmaturity The hips should be flexed and then caused by fetal malnutrition due to abducted. A “clunk” suggests the placental inadequacy may be present. presence of congenital dislocation The normal healthy baby who is warm (Ortolani’s sign). and dry, sleeps most of the time unless hungry, when she cries lustily. Second Examination (Within 5-7 days of delivery) The state of consciousness is This includes the same aspects as assessed, since brain damage around the first examination with additional birth (perinatally) may result in obvious possibilities, due to the longer period twitching (convulsions) or drowsiness. of extra-uterine life which involves The anterior fontanelle is palpated. potential infection, inadequate takeover The respiratory rate is about 40/minute. of previous placental functions (such Percussion and auscultation require as clearing bilirubin) and alterations in practice but are of limited value as circulation such as the normal closure compared to observation. Observation of the ductus arteriosus. of respiratory difficulty with excessive thoracic movement is a good indicator The new-born loses 10-15% of body of respiratory distress. The heart rate is weight and may take 10-14 days around 140/minute and replaces pulse to regain h einuria, bile pigments, counts. The presence or absence of reducing substances, pyuria and cyanosis centrally and peripherally is phenylketones. Examination of the ears noted and femoral pulses defined. is a routine and important part of the The number of umbilical arteries examination of older infants and any present febrile children, but is difficult and not is again noted. Blood pressure is only essential in the healthy neonate. recorded in specific cases. The examination of preterm babies (prematures) requires special expertise only acquired by experience.

52 The umbilicus should be examined The ability to hear is present within for possible inflammation (Omphalitis) the first day. It is relatively easy to test and the eyes should be inspected for whether a baby hears a loud noise and conjunctivitis varying from non-specific responds but very difficult to assess the “sticky-eye” to fulminating gonococcal range of tones heard. When the baby is ophthalmia. Make a smear as well as a few months old she will turn towards a culture of conjunctival discharge. a sound such as a bottle clinking or The withdrawal of maternal hormones a door shutting. The baby aged a may result in breast engorgement and few months has a wide tonal range lactation (witch’s milk). Do not squeeze of hearing. The young infant soon the breast or mastitis may occur. appreciates temperature differences, touch and painful stimuli. Motor Older Babies and Children development is slower but the deep Examination of the baby after the first tendon reflexes are present from week of life is modified by growth an early age as are the cremasteric and by the increasing importance of and abdominal reflexes. assessing development , in addition to detecting evidence of health or disease. The plantar responses are initially of an extensor type and do not become flexor Ammoniacal (nappy rash) until the age of walking (15-18 months). due to urea in stale urine being split to ammonia may be seen and At birth some primitive reflexes are occasionally monilial infection affects present, such as the Moro reflex (a the same area. Napkin rash tends not sudden extension of arms and legs on to affect inside the skin folds whereas ‘alarm’, such as a loud noise, vibration monilia does so and scatters daughter or feeling of dropping), a “rooting” areas of infection. Monilia is a common reflex with the mouth turning towards a cause of stomatitis and may be seen in touch like a nipple or teat, a grasp reflex the mouth of affected babies as white of an object such as a finger and a spots which bleed on removal. walking reflex. All but the rooting reflex disappear by the age of three months. The development of various sensory The ability to control the head and functions is very rapid. Within hours of the neck when held prone or supine birth the infant can see a bright light develops in the first few months (head control) and by the age of six months to some extent and this ability rapidly a baby with normal sight and motor improves so that she will “follow” a development can reach out and grasp light when aged two months. Binocular a toy, or remain seated propped up with vision and the ability to assess the only one pillow. By the age of one year position of an object in space (e.g. the average baby can sit herself up, a rattle) is present by the age of six stand holding onto a support and crawl. months and the ability to perceive Walking alone and saying single words and recognise colours by 2-3 years of may be accomplishments by one year age. Cataract is not rare in babies and or may not appear until aged 11/2 should be looked for. years.

53 Phrasing usually begins by the age of The anterior fontanelle, where the 18 months but is extremely variable in sagittal and coronal sutures cross, is age of commencement, and may not normally “open” at birth, as are the be established even by 21/2 years in sutures, to permit growth of the . a normal baby. The anterior fontanelle is felt routinely to determine its size and whether it is Physical development must be taken tense and bulging, normal or concave. into account. The average baby Normally it closes by the age of 18 doubles her birth weight (3.2kg.) by months but delay occurs in some six months, trebles it by one year and diseases. quadruples it by two years. Growth is no less spectacular from an average A bulging, tense fontanelle suggests 50cms at birth to 75cm at one year. underlying meningitis, hydrocephalus Height, weight and head circumference or subdural haematoma. Premature are plotted against standards on closure of the sutures leads to a range centile charts and if they lie between of abnormal skull shapes. the 3rd and 97th centile and follow approximately the same channel this An essential part of infancy and is satisfactory. childhood is growth and apart from relative length of head, trunk and Excessive emphasis should not be limbs, the specific effects of vitamin placed on total weight or weight gain, deficiencies, such as infantile but having said that, a baby who is not and scurvy, are looked for. gaining weight is failing to thrive and a The earliest sign of rickets is cause should be sought. craniotabes (softening of the skull bones where the head is most often in contact with the bedding). This The primary dentition of twenty teeth is usually the occipital area and a usually begins with the incisors (6-9 springing sensation similar to months) and ends with the molars at pressing a table tennis ball is felt 2 – 21/2 years. when the skull is squeezed and released. Examination of a rapidly growing child must be related to the appropriate The ends of the shafts of the long norms for her age. The average heart bones become enlarged and are rate of 140/minute at birth does not fall felt as thickened at the wrists, knees to the adult values until puberty. The and ankles. Costo-chondral beading (rachitic rosary) is felt. The legs may respiratory rate is similarly diminished be seen to be bowed, or “knock- from 40/minute at birth to 20/minute knee” (genu varum or genu valgum) at 10 years. The temperature is much may develop. The child with scurvy more labile than in adults and children has exquisitely tender limbs due to can readily become pyrexial, especially underlying subperiosteal in the first two years of life. Similarly in haemorrhage. infants low values of less than 35oc are not unusual.

54 Lymphatic System The presence or absence of The lymphatic system of children, femoral pulses is always recorded; such as adenoids, tonsils, thymus absent or weak pulses suggest the and regional lymph glands, normally possible presence of a coarctation increase in size for the first five years (narrowing) of the aorta. Blood of life and become smaller as puberty pressure in older children is progresses. “Large” tonsils are estimated by sphygomomanometry normal in children and are not usually using cuffs progressively wider indicative of disease. Associated in size. Small cuffs give higher infection and cervical adenitis are readings so the size must be more important. Large adenoids may recorded. be suspected when is seen or reported and may be associated with postnasal drip and In infants and children not only aspiration bronchitis. does the scale alter on abdominal examination but specific tests are Respiratory System required such as the test feed for the presence of hypertrophic pyloric Examination of the respiratory system stenosis. (“Test Feed”). should always include ascertaining the position of the trachea, since The infant is fasting, with the mediastinal shift readily occurs in stomach emptied by gastric tube children. The breath sounds are if necessary. The baby is fed lying different from those of the adult,being supine on a table or cot in a warm harsh vesicular in type and often room and her abdomen is exposed. mistaken for bronchial breathing. A physician with warm hands sits or

stands on the left side of the baby. Practice is required not only in auscultation but in defining the position of the lung margins and The upper part of the abdomen is of underlying viscera, such as the gently palpated; as the stomach fills the liver in babies and children at various abnormal pyloric sphincter is felt to be ages. hypertrophied and like a “hazel-nut”. The peristalsis of the enlarged stomach The ears should always be examined may be seen, transmitted through the since acute otitis media is common abdominal wall as “waves” moving and foreign bodies and perforated drums are not uncommonly found. from left to right. Another specific test which requires expertise to carry out Cardiovascular System is jejunal biopsy for evidence of gluten The apex beat of the child is palpable enteropathy. inside the nipple line and usually in the fourth left interspace. The blood In the examination of the abdomen it is pressure of an infant is measured by important not to handle repeatedly or the “flush” technique which indicates roughly, any mass felt, particularly in approximate systolic pressure. Thrills the area of the kidneys, since this may are felt as in adults and the heart sounds are auscultated normally with be a neoplasm which can spread. sinus arrhythmia and a third heart sound more commonly present.

55 One finding almost unique to infants is an apparently spontaneous intussusception of gut. On palpation one feels an “empty” area and a mass which is the site of the telescoped gut. Observation of such a child, usually male and aged 3-15 months, indicates episodes of severe colic with pallor and crying and sometimes blood per rectum. (“Red currant jelly”). This intussuscepted mass may only be felt when the child has been anaesthetised. Routine examination of a boy includes palpation for the testes which may be undescended, ectopic or retractile. In the older child signs of the onset of puberty should be observed and recorded. This is very variable in onset but tends to begin in girls aged 8-11 years and boys aged 10-13 years. The presence of pubic hair and breast swelling or testicular and penile enlargement can be noted and assessed in comparison with charts which are available.

Finally two points are emphasised. The examination of the child is never complete until the urine has been examined for (at least) proteinuria, haematuria, glycosuria and pyuria. The young child cannot complain of urinary symptoms.

A child with pyrexia of unknown origin should; • Have her urine cultured • Have her blood cultured • Have a lumbar puncture prior to starting antimicrobial therapy.

56 Psychiatric Case Family history First, ask a broad question to establish History if anyone in the patient’s family has suffered from mental illness. Presenting complaint • In cases of adoption or • Patient’s name step-parents, note information • Age regarding biological and social family. • Demographic information • For all first degree relatives – • Reason for referral and by whom. mother, father, siblings, children – age, age of death (if deceased) History presenting complaint and cause of death, history • This is an account of the patient’s of mental illness, history of history in their own words. physical illness, occupation, • Explore thoroughly what they quality of relationship with patient in presented with, for example, low childhood and thereafter. mood, hearing voices, etc. • Explore for other symptoms – Social history mood, psychosis, anxiety • housing – type of accommodation, • Always think about risk – to health, any issues safety or welfare to self or others • employment, source of income • money worries – debt, money Past lenders, loan sharks, gambling problems, etc. • Diagnosis • smoking • When first referred to psychiatry • alcohol – amount, features of • Treatment by GP for mental illness. harmful use or dependency • Current input – ? attends outpatient • drugs – what substances used, clinic, CPN, psychology, amount, features of dependency occupational therapy, 3rd sector support • Previous treatments, dates given Personal history and what helpful • history of birth trauma, place of • Previous hospital admission birth • Previous detentions under the • family circumstances in childhood Mental Health Act • early (pre-school) childhood – • Previous DSH developmental difficulties, bedwetting, temper tantrums • history of physical or sexual abuse • Any significant past or current neglect, emotional abuse medical history • primary school – educational achievement, enjoyed/didn’t enjoy, Drug history friends, trouble, suspension, expulsion, truancy • Current medication • secondary school - educational • Compliance achievement, enjoyed/didn’t • Side effects enjoy, friends, trouble, suspension, • Over the counter medication expulsion, truancy, qualifications • Drug allergies achieved, age of leaving school • If appropriate, then past medication • further education – adjustment, history qualifications

57 • employment history – chronological list of jobs, how they were, relationships with colleagues, why they ended • current employment – how is it • relationships – past and present, significant, how long did they last, how were they, why did they end • friendships – supportive, confiding? • hobbies/interests • religion

Forensic history • past and pending charges • previous convictions • previous imprisonment • history of physical aggression, even if not charged

Premorbid history • ask the patient to describe what they were like before they were ill • how would their friends describe them • relationships – shy or makes friends easily, lasting or superficial friendships, few or many • prevailing mood – generally cheerful or gloomy, changes in mood • hobbies and interests • how would they usually respond to stress

58 Mental State Aetiology • Predisposing factors Examination • Precipitating factors • Perpetuating factors Appearance and behaviour Investigations Speech rate, tone ,volume • Biological/psychological/social

Mood high, low, euthymic, reactive, Management flat, blunted • Physical treatment • Psychological treatment Thought - • Social treatment

• Content: delusions, overvalued Prognosis ideas, what is on the patient’s mind, The psychiatric case history may seem any thoughts of harming self or long in comparison with other histories. others. The student should try to empathise, i.e. ‘feel oneself into’ the patient’s • Form: any disturbance in the flow of internal experience. Sometimes it is thought better to complete a case history over several shorter sessions rather than Perception hallucinations in any over one long one. modality Patients may struggle to answer Attention / Concentration questions for many reasons - for example, they may be responding to Insight: does the patient think they auditory hallucinations, which are far are ill, have a mental illness, require more compelling to the patient than treatment or require hospital treatment? what a student or doctor is saying.

Summary They may have persecutory delusions Two sentences summarising patient’s which cause them to be guarded or name, age, demographics, significant hostile, or they may be confused and clinical information, significant social disorientated. It is important to try to information, anything else important formulate such difficulties as giving in history. valuable information about a patient’s mental state rather than as a ‘problem’ Differential diagnosis because they don’t give a ‘good 1. Mood history’. 2. Psychosis 3. Anxiety It is often helpful to get a collateral history from a friend or relative of the 4. Substance misuse patient. For children, adolescents and 5. Organic people with learning disabilities, getting 6. Personality information from an informant such as 7. No mental illness a parent is essential.

59 Psychiatric “Systemic” • Is there anything you’re enjoying Enquiry doing at the moment/ Have you lost Although there is no such thing as a interest in things you used to enjoy? ‘systemic enquiry’ in psychiatry, it can • How’s your self esteem? What is be useful to have a set of questions your opinion of yourself, compared about mood, psychosis and anxiety to other people? Do you feel to explore the patient’s symptoms. inferior or worthless? • How are your confidence levels? Mood disorders Is there anything weighing on your mind? Do you have a sense of guilt about anything? Depression • What do you look forward to? • How have you been feeling in How do you feel about the future? yourself recently? • Is your mood constantly low? Suicide and deliberate self • Do you have good days as well? harm • When did this start? Have you ever felt so low that you have • Is there any reason you’re feeling harmed yourself in any way? Do you low? ever feel so low that you felt that life is • Does your mood vary throughout the not worth living? Have things seemed day? so bad that you’ve felt like ending it all? • Do you find yourself tearful? Have you ever thought about ways that • Does anything help lift your mood? you might kill yourself? Do you think • Does anything make it worse? you would ever carry out these plans? • How’s your sleep? • Have you got any trouble getting off It can feel really difficult to ask to sleep? questions about suicide. There is no • How long do you lie awake for? evidence that asking about suicide • Is your sleep disturbed through the increases the likelihood of a patient night? carrying it out. It can sometimes really • Do you wake early in the morning? help a patient to talk about their suicidal • What time? (early morning wakening thoughts. –two hours before normal) • What has your appetitie been like Elation recently? Have you felt that your mood is better/ • Have you had any weight loss? higher than usual recently? Have you • How much? Over what time period? felt more cheerful than usual lately? • What’s your concentration been like How are your energy levels at the recently? Can you read a magazine/ moment? Do you find you’re being watch TV? more active than usual? Is it hard • How are your energy levels? Do you for you to relax? Do you feel able to seem to be slowed down or tired? achieve more than usual in a day? • Has there been any change in your interest in sex? How is your sleep? Have you been sleeping less than usual? Do you find you’re ‘burning the candle at both ends’?

60 How is your concentration at the Persecutory delusions - Do you ever moment? Are you able to read a feel that people are talking about you magazine/read a newspaper/watch a behind your back? Do you feel that TV program? Can you do this without people are watching you? Do you ever your mind wandering? feel that people are trying to harm you? Do you think there is a conspiracy Do you feel as if your thoughts are against you? racing? Do you find your thoughts are coming faster than usual? Do you find Delusions of reference - Do you ever you’re having lots of good ideas at the feel that the television or radio has moment? specific messages for you only? Do you feel that they are speaking only to you? Do you feel you have any special Do you see any reference to yourself in abilities or talents (grandiose ideas)? the TV or newspapers?

Psychosis Alienation of thought - Can you think clearly or is there any interference with Delusions your thoughts? • ‘A delusion is a false, unshakeable idea or belief which is out of keeping Thought insertion - are thoughts put with the patient’s educational, into your head which are not your own? cultural and social background; it is held with extraordinary conviction Thought withdrawal - do thoughts ever and subjective certainty. seem to be taken out of your head as Sim 1988 if some external force or person were removing them? The patient will not usually recognize their delusional thoughts to be a feature Thought broadcast - are your thoughts of their illness and so it’s not usually broadcast so that other people know possible to ask, “Have you any unusual what you are thinking? Do you feel that thoughts?”, for example, and get an your thoughts are available to others? informative answer. Passivity phenomena Often a patient’s delusional beliefs Do you ever feel under the control become apparent over the natural of some force or power other than course of the psychiatric case history yourself? So you feel as though you are but it’s good practice to start with a possessed by someone or something couple of open questions and know else? What is that like? Does this force how to ask questions about a few make your movements/influence your specific types of delusions. emotions/make you say things you don’t want to say without you willing it? Open questions - Is there anything What’s the explanation for this? particularly on your mind? Has anything strange or unusual happened to you recently?

61 Hallucinations • Cognitive symptoms A hallucination is a perception in What kind of things are on your the absence of an external stimulus. mind? What do you worry about? They are subjectively indistinguishable Are you able to distract yourself from from a normal stimulus and can occur your worries? Are these worries in any modality. there all the time or only in certain situations? • Auditory hallucinations Do you ever seem to hear voices or For Differential diagnosis noises when there is no one – do you find unpleasant thoughts about and nothing else to explain coming into your head when you it? Do you hear the voice through don’t want them to? What are these your ears or inside your head? Are thoughts? Do you try to resist these they as clear as me talking to you thoughts? Do you recognize them know? What do they say? How many as your own thoughts? How much of voices do you hear? the day do you spend thinking about Does the voice talk to you or about these? you? Do they comment on what you are doing? Do you hear your thoughts spoken aloud? Do they command you to do things? Can you resist them or do youfeel compelled to act? Are you able to make them go away?

Anxiety The symptoms of anxiety can be split into physical symptoms, cognitive symptoms and behavioural symptoms. It’s good to start with some open questions.

• Open questions Do you find you’ve been feeling nervous or uptight recently? What kind of things make you feel like this? Do you feel like you’re always on edge?

• Physical symptoms How do you feel physically when you’re feeling anxious? Do you feel short of breath/heart racing/ butterflies in your stomach/sweaty palms/dry mouth/shaky? Do you find you can’t sit still? Do you find it hard to relax?

62 Behavioural Symptoms

Is there anything you avoid doing because of your anxiety? What impact does your anxiety have on your life?

For compulsive rituals, do you do anything in order to get rid of these unwelcome thoughts? What do you do? Do you have to repeat these actions over and over again? Do you feel compelled to carry out these rituals even though you don’t get pleasure from them? Do you get anxious if you do not carry out these rituals? What happens if you try to resist these rituals? What do you think would happen if you didn’t carry out these rituals? How much of the day is spent on these rituals?

Panic attacks Have you ever had a situation where you were overwhelmed with fear, had a racing heart and difficulty breathing? What was it like? What were your thoughts? How often do you have these episodes? Is there any trigger to these episodes?

63 Notes

64 Notes

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