Distribution solitary lesion, fl exor aspects of limbs/trunk, extensor aspects of limbs/tru nk, scalp/eyebrows/gutters of nose, sun-exposed sites, tip of nose, helix of ear, in webspa ces of hands or feet, periumbilical. Morphology noting or describing the appearance of the rash using the terms on b p139 (Table s 3.14 \200\2233.17) refi nes the list of diff erential diag- noses. Hair alopecia (hair loss) may be generalized or localized, hirsuitism (hair in the typical male distribution), hypertrichosis (excessive hair growth). Nails clubbing, pitting, ridging, onycholysis, nail loss, thinning of nail plate, discolour ation. OHFP.indb 138 OHFP.indb 138 30/05/2014 16:17 30/05/2014 16:17 139 SKIN Table 3.14 Non-palpable skin lesions Bruising; discolouration from blood leaking into the skin Flat well-defi ned area of altere d skin pigmentation Non-blanching pinpoint-sized purple macule Purple lesion resulting from free red blood cells in the skin non-blanching Abnormal visible dilatation of blood vessel s (spider naevi) Ecchymosis Macule Petechia Purpura Telangiectasia Table 3.15 Palpable skin lesions Solid, mostly subcutaneous lesion (>0.5cm diameter) Raised well-defi ned lesion (<0.5cm dia meter) Raised fl at-topped lesion, usually >2cm diameter Transient raised lesion with pink margin Weals with pale centers and well-defi ned pink margins Nodule Papule Plaque Weal Urticaria Table 3.16 Blisters Fluctuant swelling containing pus beneath the epidermis Fluid-fi lled blister larger than a vesicle (>0.5cm diameter) Well-defi ned pus-fi lled lesion Fluid-fi lled blister (<0.5cm d iameter) Abscess Bulla Pustule Vesicle Table 3.17 Skin defects Linear break in the skin surface (a scratch) Thinning and loss of skin substance Dried brow nish/yellow exudates Superfi cial break in the continuity of the epidermis Scraping off sup erfi cial layers of the skin (a graze) Crack, often through keratin Break to the skin by sh arp object Break to the skin caused by blunt trauma/tearing injury Skin thickening with exa ggerated skin markings Fragment of dry skin Loss of epidermis and dermis resulting in scar Excoriation Atrophy Crust Erosion Abrasion Fissure Incisional wound Laceration Lichenifi ca tion Scale Ulcer _OHFP.indb 139 _OHFP.indb 139 30/05/2014 16:17 30/05/2014 16:17 140 CHAPTER 3 History and examination Oncological/hematological History Symptoms weight loss, anorexia, weakness, lethargy, fatigue, cough, haemoptysis, sh ortness of breath, postural dizziness, nausea, vomiting, diarrhea, constipation, PR bleedin g, lumps, swelling, pain, fractures, bone pain, polyuria, prostatism, bruising, recurrent e pistaxis, haemarthrosis, heavy menstrual loss, recurrent miscarriage, fevers, infections, f ocal neurology. Past medical history DM, asthma, iBP, IHD, liver disease, jaundice, thyroid problems, anemia, malignancy (and radiotherapy), epilepsy, gastric or small bowel surgery, malabsorption, chronic disease (eg RA), blood transfusions, splenectomy. Drug history chemotherapy (regimen, date of last dose, response, side eff ects), iron, B12/ folate, aspirin, anticoagulants, vaccinations post-sple- nectomy, long-term antibiotics, OC P, allergies. Social history smoking, alcohol, family support, living circumstances, home help, occupatio n, previous exposure to dyes/asbestos/coal tar, racial origin, diet (vegan, vegetarian), re creational drug use. Family history malignancy, thalassaemia, sickle-cell anemia, hemophili a, von Willebrand \200\231s disease, pernicious anemia, spherocytosis, thrombophilia. Examination General inspection bruising, pigmentation, rashes and nodules, ulceration, cyan osis, plethora, jaundice, excoriations, racial origin (haemoglobinopa- thies and thalassaem ias). Hands nails (koilonychias, pallor, clubbing), palmar crease pallor, arthropathy. Face eyes (jaundice, pallor), mouth (gum hypertrophy or bleeding, ulceration, candida, atrophic gloss itis, angular stomatitis, gingivitis). Lymph nodes cervical, axillary, epitrochlear (elbow) , inguinal. Bones bony pain in sternum, spine, clavicles, scapulae. Abdomen hepatomegaly, s plenomegaly, para-aortic nodes, ascites. Legs vasculitis, bruising, pigmentation, ulceratio n, neurological signs. Other fundi (hemorrhages, engorged veins, papilloedema), temperature chart, urinalysis. OHFP.indb 140 OHFP.indb 140 30/05/2014 16:17 30/05/2014 16:17 141 BREAST Breast History Lump size, duration, mobility, pain, nipple discharge/bleeding/inversion, skin chan ges, previous breast lumps. Past obs/gynae history number of pregnancies, age of fi rst pregnancy, breastfeeding, menar che, menopause. Past medical history DM, asthma, iBP, IHD, clotting problems, liver disease , anemia, previous malignancy, epilepsy. FH breast cancer, gynae cancer. DH HRT, COC use. Examination (lying at 45 ) Examine both breasts (normal side fi rst): Inspection asymmetry, scars, skin changes, nipple discharge/inversion, skin tethering, eryt hema, oedema. Palpation ask the patient to show you where the lump is, palpate all four quadrants (see Fi g. 3.5) and axillary tail, assess any palpable masses. Lymphadenopathy axilla, cervical, su praclavicular. Other liver, spine. (a) (b) Supraclavicular lymph nodes 15% upper inner quadrant 50% upper outer quadrant 18% nipple Axillary lymph nodes 11% lower outer quadrant 6% lower inner quadrant Fig. 3.5 Anatomy of the breast. (a) Quadrants of the breast showing proportion of breast ca ncer by location. (b) Glands and lymphatics of the right breast. _OHFP.indb 141 _OHFP.indb 141 30/05/2014 16:17 30/05/2014 16:17 142 CHAPTER 3 History and examination Eyes History Symptoms reduced/impaired vision or visual loss, red eye, discomfort (gritty o r FB sensation), pain of the eye or soft tissues around the eye, dry eyes or excessive wate ring, itch, swelling, photophobia or haloes around lights, fl oaters or fl ashing lights, d iplopia, discharge. Past ophthalmic history glaucoma, myopia, cataracts, previous surgery, glasses/contact lens prescription and last optometry check-up. Past medical history numerou s systemic diseases can aff ect the eye, including DM, iBP, vascular disease, RA, SLE, thyr oid disease, MS. Drug history ophthalmic medications, steroids, medications for coexisting disease; allergies. Family history glaucoma, retinoblastoma. Social history ability to self -care, impact eye disease has upon ADLs and home support received/needed. Upper eye lid Limbus Pupil Conjunctiva over sclera Medial canthus Lateral canthus Iris with lens beneath Lower eye lid Fig. 3.6 Surface anatomy of the right eye. Examination Inspection exophthalmos, proptosis, jaundice, pallor, xanthelasma, eyelids (cys ts, infl ammation), red eye, corneal arcus, periorbital cellulitis (Fig. 3.6). Visual acuit y this must be tested in all patients: \200 Use a Snellen chart at 6m to test visual acui ty \200 Make sure the patient is using the correct glasses for the test (reading vs. distance) if in doubt use a pin-hole in a piece of card If visual acuity is very bad assess ability to count \201 ngers, awareness of movement (w aving hand) or perception of light (pen torch). Pupillary response and re \202 exes check the pupils are equal, reacting to light and acco mmodation (PERLA) and for a relative aff erent papillary defect. Look for the red refl ex ( absent in dense cataracts). Visual \201 elds confrontation testing to identify any visual fi eld loss and to establish if the defect is unilateral or bilateral (b p133). Ocular mov ements look for loss of conjugate gaze or nystagmus. Ophthalmoscopy \200 With the ophthal moscope set on +10 the cornea and anterior chambers can be examined. 1 or 2 drops of fl uor escein highlights corneal ulcers, abrasions and foreign bodies, especially under the blue l ight With the ophthalmoscope set on 0 the user can visualize the retina. It is important to dilate the pupil with 1 or 2 drops of a weak mydriatic (eg 0.5% or 1% tr opicamide) to allow full visualization of the retina. The risk of causing acute glaucoma wi th mydriatics is small. OHFP.indb 142 OHFP.indb 142 30/05/2014 16:17 30/05/2014 16:17 143 EYES Table 3.18 Descriptive terms in ophthalmology Alteration in lens and pupil to focus on near/far objects Ability of the eye to discriminat e fi ne detail Chamber anterior to the lens, containing aqueous Fluid-like jelly in the ant erior chamber of the eye Infl ammation/infection of eyelids Medial or lateral junction of t he upper and lower eyelids Conjunctival oedema Layer sandwiched between retina and sclera M ucous membrane covering sclera and cornea anteriorly Ciliary muscle paralysis preventing ac commodation Infl ammation of the lacrimal sac Eyelids evert outwards (away from the cornea) Eyelids invert towards the cornea (lashes irritate cornea) Highly cone-rich area of the ma cula (yellow-spot) Area of the retina visible with the ophthalmoscope Blood in the anterior chamber seen as a red fl uid level Pus in the anterior chamber seen as a white fl uid leve l Border between cornea and sclera Rim around the fovea, rich in cone cells Agent resulting in pupillary constriction (eg pilocarpine) Agents resulting in pupillary dilatation (eg tr opicamide) Depression in the center of the optic disc Optic nerve head seen as white opacit y on fundoscopy Chamber between the iris and ciliary body Age-related reduction in near acu ity (long-sightedness) Drooping eyelid(s) The visible white fi brous layer of the eye Defec t resulting in loss of a specifi c area of vision Squint, loss of conjugate gaze Apparatus for indirectly measuring intraocular pressure Jelly-like matter which occupies the globe be hind the lens Accommodation Acuity Anterior chamber Aqueous Blepharitis Canthus Chemosis Choroid Conjunct iva Cycloplegia Dacryocystitis Ectropion Entropion Fovea Fundus Hyphaema Hypopyon Limbus Ma cula Miotic Mydriatic Optic cup Optic disc Posterior chamber Presbyopia Ptosis Sclera Scoto ma Strabismus Tonometer Vitreous _OHFP.indb 143 _OHFP.indb 143 30/05/2014 16:18 30/05/2014 16:18 144 CHAPTER 3 History and examination Head and neck History As well as a good general history, specifi c symptoms to note include: \200 Ears pain, blocked ears, wax, discharge, tinnitus, deafness, unilateral/ bilateral features, ver tigo, trauma, itching, foreign bodies (FB), noise exposure, occupation Nose blocked nose, watery discharge, sneezing, itching, coughing, change in voice, altered sensation of smell/taste, external deformity/ recent trauma, epist axis, sinusitis; ask about daytime variation in symptom severity, pattern of obstruction, e ff ects on speech and sleep Throat dysphagia, pain on swallowing, hoarseness, diffi culty opening jaw (trismus), strido r, sleep apnoea/snoring; ask about neck lumps, vomiting, heartburn, waterbrash (acid regurg itation or fi lling of mouth with saliva). Examination \200 Ears inspect the pinna, auditory meatus, tenderness over pinna or mastoi d; otoscopy examine all four quadrants of the eardrum (see Fig. 3.7) (color, bulging/retrac tion, perforation, exudate); test hearing (see Hearing tests ) Nose look for obvious scars, deviations/deformities, tilt the head back and look down each nostril (Fig. 3.8); rhinoscopy (administer lidocaine spray fi rst), look for polyps, infl amed turbinates, pus Throat inspect the lips, around and inside the mouth; examine the tongue and tonsils using a torch and tongue depressor, check palate movements by asking the patient to say \200\230 ah \200\231 (Fig. 3.9) Neck look for swellings, asymmetry, scars; ask the patient to swallow, protrude the tongue; palpate the neck from behind and ask the patient to take a si p of water; feel for tracheal deviation, lymphadenopathy, tenderness; auscultate for a brui t; examine any lumps (see b p458). Hearing tests (OHCS8 b p540) \200 Whisper a diff erent number into each ear, standing 30c m away whilst blocking the other ear. Ask the patient to repeat it in turn. Tuning fork tests: Rinne \200\231s test place the tuning fork on the patient \200\231s mastoid bone until it i s no longer heard; then place the fork near the external auditory meatus where it is still heard in a normal ear, but not in an ear with conductive deafness Weber \200\231s test place the tuning fork in the middle of the forehead and ask which side the sound is loudest; in nerve deafness the sound is loudest in the normal ear, in conduct ive deafness the sound is loudest in the abnormal ear. OHFP.indb 144 OHFP.indb 144 30/05/2014 16:18 30/05/2014 16:18 145 HEAD AND NECK Tympanic membrane (pars flaccida) Handle of malleus Antero-superior quadrant Tympanic membrane (pars tensa) Antero-inferior quadrant Postero-superior quadrant Postero-inferior quadrant Cone of light Fig. 3.7 Structures and quadrants of the right tympanic membrane (eardrum) as seen on otosc opy. Frontal sinus Superior turbinate Sphenoid sinus Middle turbinate Inferior turbinate Eustachian tube Nostril Nasopharynx Soft palate Hard palate Fig. 3.8 Anatomy of the nose. First premolar Canine Posterior wall of oropharynx Hard palate Palatine raphe Soft palate Uvula Second premolar Lateral incisor Palato- pharyngeal arch First molar Central incisor Second molar Palato- glossal arch Dorsum of tongue Third molar (wisdom tooth) Palatine tonsil Fig. 3.9 Anatomy of the mouth and oropharynx. _OHFP.indb 145 _OHFP.indb 145 30/05/2014 16:18 30/05/2014 16:18 146 CHAPTER 3 History and examination Musculoskeletal History Symptoms joint pain, swelling, deformity, morning stiff ness, instability, sensory changes, back pain, limb pain, muscle/soft tissue aches, cold fi ngers and toes, dry eyes a nd mouth, red eyes, systemic symptoms (fatigue, weight loss, tight skin, fever, rash, diarr hea), injury/trauma (mechanism, timing, change in symptoms since), bleeding tendency. Past medical history previous trauma/surgery, recent infections (streptococcal, gonorrhoeal , tuberculosis etc), insect/tick bites, IBD, skin disease (psoriasis), childhood arthritis, hemophilia. Drug history previous anti-arthritic agents (NSAIDs, steroids (oral/ intra-articular), DMAR Ds) with benefi cial/side eff ects, long-standing steroids, Ca2+ supplements, vitamin D ana logs, bisphosphonates, other concurrent medications (antihypertensives etc), allergies. Activities of daily living ability to: bathe, dress (and undress), eat, transfer from bed t o chair and back, use of the toilet; ?change with symptoms. Social history domestic arrange ments (who else is at home, location of bathroom in relation to bed), smoking history, drug and alcohol use. Family history rheumatoid, gout, osteoarthritis, haemochromatosis, infl ammatory bowel dise ase, hemophilia. Examination Each joint has a specifi c examination routine, though the underlying principle s for each are very similar: General inspection overall appearance of the patient and their gait. Look close inspection of the joint, comparing left to right if possible. Feel assessment of warmth, tenderness, c repitus, eff usions etc. Move active (patient moving the joint) and passive (examiner movin g joint) movements; stressing joint where appropriate. Measure range of movements (in degrees) and degree of joint laxity. Ilium Anterior superior iliac spine Pubis Femoral head in acetabulum Pubic tubercle Greater trochanter Obturator foramen Ischium Femur Lesser trochanter Fig. 3.10 Anatomy of the left hip joint. OHFP.indb 146 OHFP.indb 146 30/05/2014 16:18 30/05/2014 16:18 147 MUSCULOSKELETAL Hip (OHCS8 b p680) (Fig. 3.10) Inspection leg shortening, internal rotation (hip dislocatio n), external rotation (fractured neck of femur), scars, sinuses, cellulitis, bruising. Palpation check bony landmarks (greater trochanter, anterior superior iliac crest) are symm etrical, warmth, crepitus and clicks on movement. Supine active and passive range of movement; fl exion (straight leg fl exion 0 \200\22390 , fl exion with knee bent 0 \200\223135 ), abduction (0 \200\22350 ), adduction, internal (0 \200\22345 ) and external (0 \200\22345 ) rotation, fi xed fl exion deformity (with h and in lumbar lordosis, check the popliteal fossa can touch the couch). Prone active and passive range of movement; extension (0 \200\22320 ). Stressing is not ge nerally undertaken for the hip. Gait Trendelenburg gait (b p136), walking aids. Other joint s knee (Fig. 3.11) and lower spine/sacroiliac (b p149). Knee (OHCS8 b p686) Inspection swel ling, erythema, resting position, varus (bow-legs) or valgus (knock-knees) deformity, scars , sinuses, cellulitis, muscle wasting of thigh muscles compared to the other side (especial ly vastus medialis). Palpation temperature, bony landmarks (head of fi bula, medial and lat eral joint lines, patella), eff usion (if large infra-patella sulci will be bulging outward s with a positive patella tap, if small try milking fl uid down from thigh and stroking fl uid from one side to the other), crepitus, clunks or clicks on movement, patella position, tenderness and mobility. Supine active and passive movement; fl exion (0 \200\223135 ), extension (0 ). Prone popl iteal fossa cysts or aneurysms. Stressing cruciates fl ex knee to 90 , immobilize the pati ent \200\231s foot by sitting on it and check the integrity of the anterior and posterior c ruciate liga- ments by pulling and pushing the lower leg, respectively collaterals fl ex kn ee to 30 , fi x the thigh with your left hand and test medial collateral (pull lower leg l aterally) and then lateral collateral (push lower leg medially). Gait limp, walking aids. Other joints hip (see previous section) and ankle (b p148). Lateral Medial Femur Patella Lateral collateral ligament Medial collateral ligament Articular cartilage Medial meniscus Lateral meniscus Head of fibula Tibia Fig. 3.11 Anatomy of the right knee joint. _OHFP.indb 147 _OHFP.indb 147 30/05/2014 16:18 30/05/2014 16:18 148 CHAPTER 3 History and examination Ankle (OHCS8 b p692) (Fig. 3.12) Inspection swelling, erythema, resting position (consider fracture \200\223disloca- tion and get immediate senior help if there is marked deviation o f the foot following trauma (b p434). Palpation temperature, bony landmarks (medial and lat eral malleolus, tibiotalar joint), crepitus, pain, swelling, eff usion, crepitus, clicks tr auma palpate proximal fi bula head to exclude its fracture, foot pulses (b p128), distal se nsation and cap-refi ll. Movement active and passive movement; plantarfl exion (0 \200\2235 0 ), dorsi- fl exion (0 \200\22315 ), inversion (0 \200\22330 ), eversion (0 \200\22315 ). Stressing is not generally undertaken for the ankle. Gait limp, walking aids, ability t o walk two paces unaided. Other joints knee (b p147) and foot (b p148). Tibia Fibula Medial malleolus Talus Lateral malleolus Calcaneus Navicular Cuboid Fig. 3.12 Anatomy of the right ankle joint. Foot (Fig. 3.13) Inspection swelling, erythema, resting position, high-arch, bunions. Palpa tion temperature, pain or crepitus along each metatarsal and phalanx, forefoot bones (navic ular, cuboid and medial, intermediate and lateral cuneiform), foot pulses (b p128), distal sensation and cap-refi ll. Movement as for ankle examination but also adduction and abducti on across the talonavicular and calcaneocuboid joints. Stressing is not generally undertake n for the foot. Gait limp, walking aids, ability to walk two paces unaided. Other joints an kle (b p148). Proximal phalanx First metatarsal (of great toe) Cuneiforms (lateral, middle, medial) Medial phalanx Distal phalanx Navicular Talus Cuboid Calcaneus Phalanges Metatarsals Tarsals Fig. 3.13 Anatomy of the left foot. OHFP.indb 148 OHFP.indb 148 30/05/2014 16:18 30/05/2014 16:18 149 MUSCULOSKELETAL Back (OHCS8 b p670) (Fig. 3.14) Inspection deformity, loss or exaggeration of thoracic kyph osis or lumbar lordosis, lateral deviation from the midline (scoliosis). Palpation with patient standing palpate each vertebra for pain; with patient prone palpate each side of pelvis for sacroiliac tenderness. Movement active fl exion (touch toes with knees together and legs straight; most people can touch their shins), extension (leaning back- wards), lateral bending (lateral fl exion) an d rotation (best assessed with patient seated so pelvis is fi xed) passive with patient sup ine, perform straight leg raise by elevating each leg in turn (0 \200\22385 ). Measure Schober \200\231s test for lumbar fl exion (mark the level of the posterior iliac s pine in the midline; make a further two marks, one 5cm below this and one 10cm above this; the distance between these two new marks measured when the patient is standing and then in full fl exion \200\223 an increase of <5cm suggests limited lumbar fl exion). Other joints hip (b p147) and knee (b p147). Cervical Thoracic Thoracic kyphosis Lumbar Lumbar lordosis Sacrum Coccyx Fig. 3.14 Anatomy of the spine. _OHFP.indb 149 _OHFP.indb 149 30/05/2014 16:18 30/05/2014 16:18 150 CHAPTER 3 History and examination Pelvis The joints in the pelvis are fi xed, however the sacroiliac joint can be palpated fo r tenderness from behind; in a trauma emergency a senior member of the trauma team may test the pelvis for instability. See Fig. 3.15. Sacrum Sacroiliac joint Sacral promontory Anterior superior iliac spine Ilium Pubis Obturator foramen Ischium Symphysis pubis Fig. 3.15 Anatomy of the pelvis. Shoulder (OHCS8 b p662) (Fig. 3.16) Inspection swelling, erythema, deformity, resting posit ion, (check from the front, side and back), scars, sinuses, cellulitis, swelling, muscle wa sting (deltoid, supraspinatus, infraspinatus). Palpation temperature, bony landmarks (acromion, clavicle, spine of scapula, cervical and u pper thoracic vertebrae), crepitus, clicks. Movement active and passive movement; abduction (0 \200\22390 with elbow fl exed, 0 \200 \223180 with elbow extended), adduction, internal (0 \200\22390 ) and external (0 \200 \22365 ) rotation, fl exion (0 \200\223180 ) and extension (0 \200\22365 ), passive abdu ction should be undertaken carefully if painful. Stressing Impingement test arm held at 90 abduction and internally rotated, if pain detec ted it is a positive test Scarf test patient \200\231s left hand placed over their right sh oulder and vise versa, if pain detected it is a positive test (acromioclavicular joint path ology). Other joints elbow (b p151) and back (b p149). Anterior view Posterior view Acromioclavicular joint Spine of scapula Clavicle Acromion Acromion Greater tuberosity Lesser tuberosity Humerus Scapula Fig. 3.16 Anatomy of the right shoulder joint. OHFP.indb 150 OHFP.indb 150 30/05/2014 16:18 30/05/2014 16:18 151 MUSCULOSKELETAL Elbow (OHCS8 b p666) (Fig. 3.17) Inspection swelling, erythema, infl amed bursae, rheumatoi d nodules or psoriatic plaques over the olecranon, scars. Palpation temperature, bony landmarks (medial and lateral epicondyles, olecranon), crepitus , clicks, instability. Movement active and passive movement; fl exion (0 \200\223150 ) and extension (0 ); prona tion, supination. Stressing is not generally undertaken for the elbow. Other joints shoulder (Fig. 3.16 b p15 0) and wrist (Fig. 3.18). Anterior view Posterior view Medial supracondylar crest Medial condyle Lateral condyle Coronoid fossa Olecranon fossa Olecranon Lateral epicondyle Medial epicondyle Lateral epicondyle Capitulum Head of radius Neck of radius Head of radius Neck of radius Trochlea Coronoid process Fig. 3.17 Anatomy of the right elbow. Wrist (OHCS8 b p668) (Fig. 3.18) Inspection swelling, erythema, deformity (eg Colles \200 \231 fracture), features of rheumatoid disease (b p454), scars. Palpation temperature, bony landmarks (styloid process of radius, head and styloid process of ulna), scaphoid (base of the anatomical snuff -box). Movement active and passive movement; fl exion (0 \200\22375 ), extension (0 \200\22375 ) , radial (0 \200\22320 ), ulnar deviation (0 \200\22320 ), pronation, supination. Stressing is not generally undertaken for the wrist. Other joints elbow (b p151) and hand ( b p152). Capitate Metacarpals Trapezoid Hamate Pisiform Triquetrum Lunate Ulnar styloid process Ulna Trapezium Scaphoid Carpals Radial styloid process Radius Fig. 3.18 Anatomy of the wrist and hand. _OHFP.indb 151 _OHFP.indb 151 30/05/2014 16:18 30/05/2014 16:18 152 CHAPTER 3 History and examination Hand (OHCS8 b p668) (Fig. 3.19) Inspection erythema, swelling, breaks to the skin, features of rheumatoid disease (b p454) or osteoarthritis (b p454), deformity, dislocation, muscle wasting, nail pitting. Palpation temperature, palpate each metacarpal and phalanx for pain or crepitus, distal cap -refi ll and sensation. Movement active and passive movement; fl exion and extension of every MTPJ, PIPJ and DIPJ, abduction and adduction of every MTPJ, oppo- sition and circumduction of the thumb MTPJ; as k the patient to: hold a pencil and write, pick up a mug, undo a button, oppose their thumb and little fi nger (check strength of this against your own); check strength of extension and fl exion following penetrating or lacerating trauma to identify tendon injury. Stressing collateral ligaments of the digits following trauma or dislocation by attempting to deviate the phalanges medially or laterally. Other joints wrist (b p151) and inspect the elbow. Distal phalanx Middle phalanx Phalanges Proximal phalanx Metacarpal bones First metacarpal Carpal bones Radius Ulna Fig. 3.19 Anatomy of the hand, thumb and fi ngers. OHFP.indb 152 OHFP.indb 152 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank 154 CHAPTER 3 History and examination Urological History Symptoms polyuria, anuria, prostatism (urgency, hesitancy, poor stream, terminal dr ibble, nocturia), haematuria, dysuria, oedema, renal colic, incontinence, malaise, lethargy , N+V, anorexia, weight loss, itching, passing stones in the urine, incontinence, impotence , infertility, bone pain, genital discharge, genital/perineal lesion, scrotal pain, dyspare unia (pain on intercourse), foreign body (vaginal, urethral, anal), anal/peri- anal problem s. Past medical history DM, iBP, recurrent UTIs, renal/ureteric stones, myeloma, known rena l impairment/failure, previous vesicoureteric refl ux, gout, immunosuppression (steroids, H IV), neurological disease, long-term urinary catheter, STIs, spinal cord pathology; male ti ght foreskin, recur- rent balanitis, testicular pain/swelling; female number of children, m ode of delivery and any complications, last cervical smear and result. Drug history nephrot oxics (including NSAIDs, ACEi, aminoglycosides), bladder neck relaxants, infertility or imp otence drugs, antiandrogens; allergies. Social history foreign travel, ability to cope with ADLs, sex abroad, illicit drug use (smoke, oral, IV). Sexual history \200 Last sexual in tercourse (LSI) \200\223 gender of partner, type of intercourse (vaginal, anal, oral), barrier contraception used, relationship of partner (casual, long-te rm), problems or symptoms in partner, date of LSI Repeat the above for all partners in the last 3mth \200 All men should also be asked if t hey have ever had sex with another man in the past as this aff ects risk and types of STI to consider. Occupational history past and present jobs, exposure to dyes. Family history polycystic kid ney disease, DM, iBP. Examination (lying \202 at, supine) (Fig. 3.20) General inspection mental state, RR (?Kussmaul breathing), hiccups, pallor, hydration (dehydrated: sunken eyes , dry lips/tongue; \202 uid-overload: peripheral oedema, pulmonary oedema). Hands leuconychia, brown nails, pale nail beds. Arms bruising (purpura), pigmentation, scra tch marks, fi stula, BP (lying and standing). Face eyes (anemia, jaundice), mouth (dehydration, ulcers, fetor), rash. Neck JVP. Abdomen i nspect (distended bladder, scars, transplanted kidney, dialysis port), palpate (ballot kidn eys, bladder, liver, spleen, lymph nodes), percuss (enlarged bladder, ascites), auscultate (renal artery bruits), PR for prostate. Rectum size, surface, consistency and symmetry of prostate in men, fecal impaction (will wo rsen urinary retention). Back oedema, loin tenderness on percussion. OHFP.indb 154 OHFP.indb 154 30/05/2014 16:18 30/05/2014 16:18 155 UROLOGICAL Chest CVS and RS examination (pericarditis, heart failure, fl uid overload). Legs oedema, b ruising, pigmentation, scratch marks, neuropathy, prox- imal weakness (myopathy), altered r efl exes, muscle wasting. Urinalysis glucose, blood, protein, nitrites, leucocytes. Other fundoscopy (DM and iBP chan ges), blood glucose, weight. Fallopian tube Ovary Bladder Pubic bone Clitoris Outer labia Inner labia Uterus Cervix Rectum Anus Vagina Urethral meatus Bladder Pubic bone Urethra Shaft Glans Foreskin Urethral meatus Scrotum Testis (testicles) Seminal vesicles Rectum Prostate Anus Vas deferens (sperm duct) Epididymis Fig. 3.20 Anatomy of the female (L) and male (R) urogenital systems. Examination of male genitalia Inspection look for any ulceration (including retracting fore skin and checking the glans), warts, scars, or sinuses, urethral discharge, tight foreskin (phimosis) or retracted foreskin which is stuck leaving the glans exposed (paraphimosis). O bserve the scrotum for skin changes or oedema and, whilst the patient is standing, the lie of the testes (the left testis usually hangs lower than the right and both testes lie longi tudinally \200\223 a high testis with a transverse lie may indicate torsion, though a tort ed testis may also appear normal). Palpate each testis in turn between the fi ngers and the thumb feeling for texture, tendern ess, nodules, and to compare left to right. An absent testis may be maldescended and trappe d in the inguinal canal. Examine epididymis and follow it up superiorly to the spermatic co rd and up into the inguinal ring. Palpate inguinal lymph nodes or maldescended testis. Examination of female genitalia See b p156. _OHFP.indb 155 _OHFP.indb 155 30/05/2014 16:18 30/05/2014 16:18 156 CHAPTER 3 History and examination Female reproductive system History Menstrual history date of last period, length of menstrual cycle (regular or irregu lar), length of period, associated pain/symptoms (Table 3.19), age when periods started/sto pped; bleeding/discharge severity of periods (number of pads/tampons, clots, fl ooding), bl eeding between periods, after intercourse (vaginal, anal, oral), or after menopause, rectal /urinary bleeding, eff ect on lifestyle, other vaginal discharge (color, consistency and sm ell). Sexual history pain on superfi cial or deep penetration (dyspareunia), type of intercourse (vaginal, anal, oral), use of contraception, intercourse in foreign countries, previous sex ually transmitted infections; contraception current and previous types, problems/benefi ts. Cervical smear date of last test and result, previous results and any treat- ment (repeat s mears, colposcopy clinic, laser ablation). Past gynae history previous problems and/or operations (where and name of surgeon), breast or thyroid problems, use of HRT, prolapse. Past obstetric history number of pregnancies, nu mber of births, type of delivery, complications, subfertility (see b p158 for obstetric his tory). Past medical history clotting problems, thyroid problems, anemia, malignancy. Urinary problems incontinence (on laughing/coughing/exercising or spontaneous), dysuria, ur gency, frequency, haematuria, if symptomatic ask about fl uid intake, leg weakness, fecal i ncontinence, back pain and previous spinal problems/surgery, eff ect on lifestyle. Other vaginal lumps, weight loss, other concerns. Examination Always have a chaperone who can also guard the door. Ask friends and family mem bers to leave, unless the patient wants them to stay (this also provides an opportunity to ask questions which the patient may not have answered fully with others present). As with a ny examination it is essential to keep the patient informed about what you are going to do. Start with the patient lying fl at on their back with arms by their sides. See Fig. 3.21. Abdominal Assess for scars, striae, hernias, body hair distribution, everted umbilicus, dis tension, tenderness including loins ( guarding, rebound), masses, organomegaly, percuss (m asses, shifting dullness). Ask the patient to move her feet apart, bend her knees and let her legs fl op outwards. Hav e a strong light source directed at the vulva and gloves on both hands. Vulval Look for rashes, ulcers, warts, lumps or other lesions; spread the labia majora usin g your non-dominant thumb and index fi nger and look for lesions, lumps, discharge (urethra l/vaginal), bleeding; ask the patient to push down (look for prolapse) and cough. OHFP.indb 156 OHFP.indb 156 30/05/2014 16:18 30/05/2014 16:18 157 FEMALE REPRODUCTIVE SYSTEM Vaginal Insert a well-lubricated index and middle fi nger (dominant hand) into the vagina a nd feel for the cervix, noting the size, shape, consistency and whether it is mobile or ten der. Feel above, below and to the sides (adnexae) for masses or tenderness. Finally palpate the uterus by placing your other hand above the pubic symphysis and press down with the fi ngers at the cervix; pressing up feel for uterine position (anteverted/ retroverted), size , shape, consistency, mobility and tenderness. Inspect the fi nger afterwards for blood or discharge. Cusco \200\231s speculum Whilst the patient is in the same position insert a wel l lubricated and warmed speculum into the vagina. Look at the cervix for ulceration, bleedi ng, cysts or other lesions and the cervical os. If required take swabs and/or a cervical sm ear. Consider Sims speculum (for examining prolapses), rectal examination. Pubic bone Clitoris Bladder Uterus Rectum Cervix Fig. 3.21 Examination of the female reproductive system. Table 3.19 Descriptive terms in gynecology Anatomy Introitus the entrance to the vagina Adn exae the areas lateral to the cervix where the ovaries are located Abnormal bleeding Climac teric phase of irregular periods and associated symptoms prior to menopause Intermenstrual bleeding between periods Oligomenorrhoea infrequent menstruation, >42d menstrual cycle Meno pause the end of menstruation Menorrhagia excessive blood loss during menstruation (>80ml/c ycle) Postcoital bleeding after sexual intercourse Postmenopausal bleeding >6mth after the menopause Primary amenorrhoea failure to start menstruating by 16yr Secondary amenorrhoea a bsence of menstruation for >6mth after menstruation has started and not due to pregnancy Pain Dysmenorrhoea pain associated with menstruation Dyspareunia pain associated with sexua l intercourse, can be superfi cial (eg vulval or entrance to vagina) or deep (only on deep penetration) _OHFP.indb 157 _OHFP.indb 157 30/05/2014 16:18 30/05/2014 16:18 158 CHAPTER 3 History and examination Obstetric History Current pregnancy estimated due date (EDD), gestation, last menstrual period (LMP), method of conception, scan results, site of placenta, rhesus status, concerns, attitude to pregnancy; current symptoms bleeding, other vaginal discharge, headache, visual disturbanc e, dysuria, urinary frequency or urgency, constipation, vomiting, GORD. Previous pregnancies number of pregnancies (gravidity), number of deliv- eries \211 24/40w ks (parity), miscarriages, terminations (reason, gestation, method), stillbirths, complicat ions: vomiting, anemia, bleeding, group B strep, BP, proteinuria, gestational DM, poor feta l growth, admission. Delivery history method of delivery and reason (vaginal, ventouse, forceps, elective/emerge ncy Cesarean), gestation, birthweight, sex, complications (fever, prolonged rupture of memb ranes, CTG trace), postnatal baby problems (feeding, infection, jaundice), admission to SCB U/NNU, outcome (how is the child now), postnatal maternal prob- lems (pain, fever, bleeding , depression). Past gynae history previous problems, operations, STIs. Past medical history DVT, PE, DM, a dmissions, psychiatric problems. Family history DM, iBP, pre-eclampsia, congenital abnormal ities, DVT, PE, multiple pregnancies. Social history support from family/partner, type of housing, employ- ment, fi nancial probl ems, smoking, alcohol, substance abuse. Table 3.20 Antenatal care Gestation (wk) Standard antenatal care: purpose of each visit Booking FBC, G+S, red cell antibodies, rubella, syphilis, hepatitis B, HIV serology, sickle-cell di sease, BMI, BP, urine dipstick and culture USS for gestational assessment and nuchal screen ing Urine, BP, serum screening (for Down \200\231s and neural tube defects) USS for fetal a nomalies and growth and placental position Fundal height, BP, urine, FBC, red cell antibodi es, anti-D if rhesus \200\223ve Fundal height, BP, urine Fundal height, BP, urine, anti-D if rhesus \200\223ve Fetal position, fundal height, BP, urine Discuss induction, fetal pos ition, fundal height, BP, urine 11 \200\22314 16 20 28 25*, 31* 34 36, 38, 40* 41 For the fi rst pregnancy only. OHFP.indb 158 OHFP.indb 158 30/05/2014 16:18 30/05/2014 16:18 159 OBSTETRIC Examination Fetal heart Audible from 12wk using a Doppler ultrasound and 24wk using a Pinar d stethoscope; it is faster than the mother \200\231s (110 \200\223160bpm). Weight Plot mot her \200\231s weight and BMI (b p604) at the booking visit. Inspection Striae, linea nigra (line of pigmentation from the pubic sym- physis to the navel that darkens during the 1st t rimester), venous disten- sion, scars, oedema. Fundal height The fundus (top of the uterus) is palpable from about 12wk gestation; it shou ld be measured from the top of the pubic symphysis to the top of the fundus with a tape mea sure. Between 16 and 36wk the fundal height in centimeters should be the same as the gestat ion 2cm, eg 23 \200\22327cm at 25wk. Fundal height is unreliable after 36wk. See Fig. 3.2 2. 36 weeks 40 weeks 22 weeks 16 weeks 12 weeks Fig. 3.22 Location of the fundus as pregnancy progresses. Fetal lie After 32wk it is possible to assess the position of the fetus by palpating across the abdomen for the fetal head: \200 Longitudinal head palpable in midline \200 Obliqu e head palpable in iliac fossa \200 Transverse head palpable in lateral abdomen. Presenta tion Palpation after 32wk can also assess the presentation though this is liable to change until about 36wk. By palpating both ends of the fetus the position of the head can be deter mined: \200 Cephalic head is at the bottom \200 Breech head is at the top. Engagement T his is assessed by palpating the base of the uterus above the pubic symphysis between two h ands to assess how much of the pre- senting part is palpable. If only the top 1/5th of the presenting part is palpable the fetus has \200\230engaged \200\231. Blood pressure must be monitored regularly to assess for pregnancy induced iBP; consider urine dipstick and fundo scopy too. Urine dipstick for protein (pre-eclampsia) and glucose (DM). USS Lie, presentati on and engagement can be confi rmed on USS. _OHFP.indb 159 _OHFP.indb 159 30/05/2014 16:18 30/05/2014 16:18 160 CHAPTER 3 History and examination Psychiatric History Are you safe? sit so the patient is not between you and the door, remove all potent ial weapons, be familiar with the panic alarm, check notes/ask staff about previous violenc e, low threshold for a chaperone. Set the scene make sure you are both comfortable, ensure privacy and that you will not be d isturbed, eg give the bleep to someone else, have tissues available, emphasize confi dentia lity.