Risk factors Document recognized risk factors for important diff erentials. Past medical history Ask about previous medical problems/operations and attempt to gauge th e severity of each (eg hospital/ICU admissions, exercise tolerance (ET), treatment); use th e drug history to prompt the patient \200\231s memory. Consider documenting specifi cally a bout asthma, DM, angina,iBP, MI, stroke, PE/DVT, epilepsy. Drug history Document all drugs along with doses, times taken and any recent changes. Alway s document drug allergies along with the reaction precipitated. Alternatively if the patien t has never had a drug allergy then document this. Family history Ask about relevant illness in the family (eg heart problems, DM, cancer). Ar e other family members well at the moment? Social history This is essential: home ask about who they live with, the kind of house (eg bungalow, residential home), any home help, own ADLs (cooking, dressing, washing); mobility walking aids (stick/ frame), exercise tolerance (how far can they walk on level ground? ca n they climb stairs?); lifestyle occupation, alcohol (units/wk), smoking (cigarettes/d and pack years), recreational drugs: \200 Alcohol; 1 unit = pint of beer, glass of wine, m easure of spirits; bottle of wine = 9units, 1l of strong cider = 8.5units Smoking; 20 cigarettes/d for 1yr = 1 pack year. OHFP.indb 124 OHFP.indb 124 30/05/2014 16:17 30/05/2014 16:17 125 BASIC HISTORY Systems \200\231 review Relevant systems \200\231 review will often be part of the HPC; a t horough systems \200\231 review is only necessary if you are unsure what is rel- evant or a re struggling to explain the symptoms. See OHCM9 b p22. Chest pain, palpitations, SOB, ankle swelling, orthopnoea Cough (?blood), sputum, wheeze, S OB Abdo pain, nausea/vomiting, bowel habit (?blood), stool color and consistency, distensio n, dysuria, frequency, urgency, haematuria Headache, photophobia, neck stiff ness, weakness , change in sensation, balance, fi ts, falls, speech, changes in vision/hearing Systemic Ap petite, weight loss/gain, fever/night sweats, malaise, stiff / swollen joints, fatigue, ras hes/itch, sleep pattern CVS Resp Abdo Neuro Summarizing Ask if there are any other problems that have not been discussed and repeat bac k a summary of the history to the patient to check that they agree. It is a good idea to us e the ICE questions (Ideas, Concerns, Expectations) at this point \200\223 ask the patient if they have any idea or suspicion of what might be wrong with them, if there \200\231s an ything in particular that they \200\231re worried about (this may prompt them to admit spec ifi c concerns eg having cancer), and what they expect will happen to them whilst they are in hospital. Most patients have no idea about tests and investigations and fi nd being admitted to hospi tal a frightening event; they often value the opportunity to talk about possible options an d ask questions. Always fi nish your history by asking specifi cally if the patient has any further question s or any other issues they would like to discuss, as frequently they will be too embarrasse d/shy/reticent to ask. Should you take notes whilst clerking? There is no simple answer to this. Taking notes whil e the patient talks may allow you to record important details accurately or even to write u p your clerking as you go. This can be extremely useful during busy on-calls. Alternatively not taking notes allows you to give the patient your undivided attention and the opportuni ty to record the clerking having considered the whole picture. In the end it comes down to individual preference and workload. After the history By the end of taking the history you should have a reasonable idea of the diff erential diagnosis. Try to think of specifi c signs that would be present on examinat ion to confi rm or refute these diff erentials. A basic examina- tion is described on the n ext page. _OHFP.indb 125 _OHFP.indb 125 30/05/2014 16:17 30/05/2014 16:17 126 CHAPTER 3 History and examination Basic examination It is good practice to perform a brief CVS, RS, abdo and neuro exam on al l patients but focus your examination according to their history. Check observations (temp, BP, HR, RR, O2 sats): \200 Ask a nurse to chaperone you if necessary \200 Get consent before touching the patient, ask where it hurts \200 First assess briefl y whether the pa tient looks well or ill. Hands (b p152) \200 Inspection at the hands for signs of disease \200 Palpation check the pulse for rate, rhythm and character (eg ?collapsing pulse). Mouth \200 Inspection central cyanosis, mucous membranes, stomatitis, beefy tongue (diron), candidiasis, ulcers, dental hygiene (risk factor for SBE). Cardiovascular system (b p128) \200 Inspection JVP (very useful if visible), swollen ankl es \200 Palpation temp of hands, capillary-refi ll, carotid pulse (volume and character), apex beat, heaves/thrills, hepatomegaly Auscultation heart sounds, added sounds/murmurs (timing, volume, radiation), carotid bruits, basal crackles. Respiratory system (b p130) \200 Inspection asterixis (fl ap), stridor, JVP, RR and eff o rt (accessory muscles, recession), chest wall movement, peripheral oedema Palpation trachea, cervical lymphadenopathy, expansion \200 Percussion does right equal l eft?, hyperresonant, dull, stony dull \200 Auscultation air entry, crackles, wheeze, bron chial BS, rub. Abdomen (b p131) \200 Inspection jaundice, scars, distension, hernias, oed ema \200 Palpation start away from pain and watch patient \200\231s face: tenderness, peritonism (guarding, rebound, rigidity, percussion tenderness), masses, liver, spleen, kid neys and AAA (expansile mass), hernias, genitalia, PR (masses, stool, tenderness, prostat e, blood/mucus/melaena) Percussion ascites (shifting dullness, fl uid thrill), liver, spleen \200 Auscultation bo wel sounds (absent, reduced, increased, tinkling). Peripheral nerves (b p134) \200 Inspec tion posture, movement of limbs \200 Palpation tone; power (5 normal, 4 weak, 3 against g ravity only, 2 not even against gravity, 1 twitch, 0 none); re \202 exes tendons, plantars ; sensation Coordination fi nger \200\223nose, slide heel down opposite leg. Cranial nerves (b p133) \200 Inspection GCS, mental state (b p161), facial symmetry, scars, obvious gaze palsies, speech, posture Eyes (II, III, IV, VI) acuity, pupil reactivity, fi elds, movements, fundi \200 Face (V, VII) sensation and power \200 Mouth (IX, X, XII) tongue movements, palate position, cough \200 Other (VIII) hearing, balance, gait (XI), shrug, head movements. OHFP.indb 126 OHFP.indb 126 30/05/2014 16:17 30/05/2014 16:17 127 RECORDING YOUR CLERKING Recording your clerking The initial clerking of a patient is one of the most important step s in their journey through the hospital. It will be reread by every team that looks after t he patient and used as a benchmark for measuring the progress of the patient \200\231s cond ition. A good clerking gives the patient the best opportunity to receive the correct invest igations and treatment. Heading Your name, position, location, date, time; state clearly why the patient is being c lerked (eg referred from ED with chest pain). Format Follow a logical order setting out each section under the head- ings shown over thes e four pages. If a piece of information from a dif- ferent section is really important then write it in the history of presenting complaint and/or under the social history. Sources State where you got important information from (eg patient, relative (with name and relationship), notes, computer records). This makes it easy to check if the information is of critical importance. Use the notes Don \200\231t rely on a patient \200\231s account of their previous medical h istory, especially for investigations and results. Try to fi nd the offi cial record of key investigations rather than relying on another doctor \200\231s comments. Be thorough These pages represent a basic clerking; you should record all of the information described on th ese pages at the very least. State the obvious What appears obvious now may not be to someone reading the notes or on th e next shift, eg below-knee prosthetic leg, crying constantly. Diff erential diagnosis What diseases are likely to explain the patient \200\231s symptoms? What serious diseases need to be excluded? Make a list of these after the examination. Con sider recording the most critical evidence for and against each diagnosis. Management plan This should be a detailed list of the steps you will take to diagnose and t reat the diff erential diagnosis. It should be written in order of priority. Alongside inve stigations and treatment consider nursing measures, frequency of observations, what to do i n the event of deterioration, referrals, best location (eg respiratory ward, HDU). State what the patient was told This prevents confusion. If you are not telling the patient about a serious illness then state why. See b p74 for other tips about writing in the note s. _OHFP.indb 127 _OHFP.indb 127 30/05/2014 16:17 30/05/2014 16:17 128 CHAPTER 3 History and examination Cardiovascular History Symptoms chest pain or heaviness, dyspnoea (exertional, orthopnoea, paroxysmal noct urnal) (see Table 3.1), ankle/limb swelling, palpitations, syncope or pre-syncope, limb pai n (at rest or on exertion), fatigue, numb- ness, ulcers. Past medical history IHD, MI, hypertension, palpitations, syncope, clot- ting problems, rhe umatic fever, cardiac surgery, recent dental work, liver problems, renal problems, thyroid disease. Table 3.1 Functional status of established heart disease (NYHA) Class I Class II Class III Class IV Disease present but no symptoms during ordinary activity Angina or dyspnoea during ordinary activity (eg walking to shops) Angina or dyspnoea during minimal activity (eg making cup o f tea) Angina or dyspnoea at rest Drug history cardiac medications (and compliance), allergies. Social history tobacco, alcoh ol, and caff eine consumption, illicit drug use (?IV), occupation, exercise tolerance on fl at and stairs. Family history IHD, ilipids, cardiomyopathy, congenital heart disease. Coro nary artery disease risk factors previous IHD, smoking, iBP, ilipids, family history of IHD , DM, obesity and physical inactivity, male sex. Palpation of central and peripheral pulses Central \200 Carotid two fi ngers, medial to t he sternocleidomastoid muscle and lateral to the thyroid cartilage (do not palpate both sid es together) \200 Abdominal aorta both fi ngertips, halfway between umbilicus and xiphisternum. Arms \200 Radial two fi ngers pressed on the radial aspect of the inner wrist \200 Ulna r two fi ngers pressed on the ulnar aspect of the inner wrist \200 Brachial two fi ngers pressed into the antecubital fossa, just medial to the biceps tendon (ask patient to fl ex arm against resistance to fi nd the tendon). Legs \200 Femoral two fi ngers pressed fi rmly into the middle of the crease in the groin, halfway between the symphysis pubis and the anterior superior iliac spine. Popliteal ask patient to fl ex their knee, put both your thumbs either side of the patella and press fi rmly with your fi ngertips into the popliteal fossa . Posterior tibial two fi ngers pressed 1cm posterior to the medial malleolus. Dorsalis pedis two fi ngers pressed between the 1st and 2nd metatarsals. OHFP.indb 128 OHFP.indb 128 30/05/2014 16:17 30/05/2014 16:17 129 CARDIOVASCULAR Examination (lying at 45 ) General inspection dyspnoea at rest, cyanosis, pallor, facial f l ushing, Marfan \200\231s, Turner \200\231s, Down \200\231s syndromes, rheumatological dis orders, acromegaly. Hands radial pulses (right and left, collapsing pulse), clubbing, splinter hemorrhages, Osl er \200\231s nodes, peripheral cyanosis, xanthomata. Face eyes (pallor, jaundice, xanthelasma), malar fl ush, mouth (cyanosis, high arched palat e, dentition). Neck JVP, carotids (pulse character). Precordium inspection (scars, deformity, apex beat), palpate (apex beat, thrills, heave (Table 3.2)), auscultate (heart sounds (Table 3.3), murm urs \200\223 also auscultate with the patient in both left lateral and sitting forward pos itions). Back scars, sacral oedema, pleural eff usions, pulmonary oedema. Abdomen palpate liver, spl een, aorta, ballot kidneys, percuss for ascites, femoral and renal artery bruits, radiofemo ral delay. Legs peripheral pulses, temperature, ulceration, oedema, calf tenderness, venous guttering, thin shiny skin, loss of hair, gangrene, varicose veins, eczema, haemosiderin pigmentation of the skin (particularly above the medial malleolus), lipodermatosclerosis ( \200\230inve rted champagne bottle leg \200\231). Blood pressure lying and standing, consider also left and right arms separately. Other urin e analysis, fundoscopy, temperature chart. Table 3.2 Characteristics of valve defects Mid-diastolic rumbling murmur, loud 1st HS, opening snap, malar fl ush, AF, tapping apex, l eft parasternal heave Pansystolic murmur radiating to the axilla, soft 1st HS, 3rd HS prese nt, thrusting apex, left parastenal heave Ejection systolic murmur radiating to the neck, 4 th HS, reversed HS splitting, slow rising pulse, systolic thrill Early diastolic murmur (be st heard in expiration), collapsing pulse, wide BP, pistol-shot femoral pulse, Corrigan \200\231s sign, Quincke \200\231s sign, de Musset \200\231s sign Mitral stenosis Mitral regurgitation Aortic stenosis Aortic regurgitation Table 3.3 Heart sounds 1st (S1) Physiological; blocking of blood fl ow after closing of the mitral (M1) and tricuspid (T1) valves Physiological; blocking of blood fl ow after closing of the aortic (A2) and pulmonar y (P2) valves; aortic precedes pulmonary and splitting can be heard during inspiration Some times pathological; caused by blood rushing into the ventricles after S2; suggests increase d volume of blood in athletes, pregnancy or heart failure Pathological; blood pushing open a stiff ventricle before S1; suggests LVF, aortic stenosis, cardiomyopathy 2nd (S2) 3rd (S3) 4th (S4) _OHFP.indb 129 _OHFP.indb 129 30/05/2014 16:17 30/05/2014 16:17 130 CHAPTER 3 History and examination Respiratory History Symptoms cough, sputum, shortness of breath (see Table 3.4), wheeze, chest pain, fe vers and sweats, weight loss, hoarseness, snoring, day sleepiness. Past medical history che st infections/pneumonias (as child or adult), tuberculosis, HIV status and risk factors, al lergy, rheumatoid disease. Drug history respiratory drugs (inhalers, steroids, etc), vaccin ation history (especially BCG, Hib, pneumococcus), drugs known to cause respira- tory probl ems (bleomycin, methotrexate, amiodarone, etc), allergies. Social history tobacco use (expr essed in pack years \200\223 ie 20 cigarettes a day for 1year = 1pack year) and social exp osure to tobacco smoke if non-smoker, pets, exposure to other family members with respirato ry problems (TB etc), illicit drug use (crack cocaine, cannabis). Occupational history past and present jobs, asking specifi cally about dust exposure, asbestos, animal dander. Famil y history asthma/atopy, cystic fi brosis, emphysema. Table 3.4 Functional status of breathlessness (NYHA) Class I Class II Class III Class IV Disease present but no dyspnoea during ordinary activity Dyspnoea during ordinary activitie s (eg walking to shops) Dyspnoea during minimal activities (eg making cup of tea) Dyspnoea at rest Examination (lying at 45 ) General inspection O2 requirements, cough, audible wheeze or st ridor, rate and depth of respiration, use of accessory muscles, body habitus. Hands clubbin g, peripheral cyanosis, tar staining, wasting/weakness of intrinsic muscles, HR, fi ne trem or of B-agonists, fl apping tremor of CO2 retention. Face eyes (Horner \200\231s syndrome, anemia), mouth (central cyanosis), voice. Neck trachea position ( scars), JVP. Chest anter iorly inspect (shape, scars, radiotherapy marks), palpate (supraclavicular nodes, axillary nodes, expansion, vocal fremitus, apex beat, parasternal heave), percuss, auscultate. Chest posteriorly inspect, palpate (including cervical nodes), percuss, aus- cultate. Other peri pheral oedema, calf erythema/tenderness, temperature chart, breast examination (if suspect malignancy), abdominal examination, PEFR, sputum pot. sputum pot. Recording PEFR Ensure the meter is set to zero and fi t a new disposable mouthpiece. Stand the patient up (or sit up if unable to stand) and give them clear instructions. They should take as deep a breath as possible, before placing the meter in their mouth and closing the ir lips around the mouth- piece. Encourage them to blow out as hard and as fast as possible . Record the reading obtained, then document the best of 3 eff orts. OHFP.indb 130 OHFP.indb 130 30/05/2014 16:17 30/05/2014 16:17 131 GASTROINTESTINAL Gastrointestinal History Symptoms abdo pain, association with eating, vomiting or opening bowels, weight los s, appetite, bruising, bleeding, nausea, vomiting (appearance), dysphagia, dysuria, urinary frequency and urgency, possibility of preg- nancy; stool change in bowel habit, frequency, consistency, color, pain on passing, recurrent urge, blood (bowl or paper), off ensive sme ll, mucus. Past medical history GI bleeds, GORD, varices, gallstones, liver problems, jaundice, IBD, h emorrhoids, polyps. Drug history NSAIDs, anticoagulants, hepatotoxic drugs (b p172), opioid s, laxatives. Social history foreign travel, illicit drug use (?IV). Alcohol intake per day (in units, b p124), CAGE questions (b p104). Family history IBD, liver disease, cancer. Examination (lying \202 at on back) General inspection oedema, wasting, jaundice, anemia, lymphadenopathy, breath odor, mouth ulcers, gynaecomastia, spider naevi, bruises. Hands clubbing, nail color, palm color, fl ap, Dupuytren \200\231s. Abdomen distension (fat , feces, fl atus, fl uid, fetus), prominent veins, ten- derness (guarding, rebound), masses , organomegaly (see Tables 3.5 and 3.6), ascites, hernial orifi ces (inguinal, femoral, inc isional), bowel sounds. PR visible hemorrhoids, fi ssures and skin tags, anal tone, prostate, rectal masses, appear ance of feces blood. Table 3.5 Common abdominal masses \200\223 if in doubt check with USS RUQ, extends to RLQ, unable to get above, dull to percussion LUQ extends to RLQ, unable to get above, notch RUQ and/or LUQ, ballotable, able to get above it, smooth outline Indentabl e mass away from umbilicus Liver Spleen Kidney Feces Table 3.6 Common causes of enlarged liver and spleen Hepatomegaly alcohol, hepatitis, EBV, CMV, thin patient, autoimmune hepatitis, toxins, live r metastases, lymphoma, leukemia, haemochromatosis, amyloidosis, hyperexpanded chest eg COP D, heart failure Splenomegaly chronic liver disease, autoimmune disease, thrombocytopenia, EBV, CMV, hepatitis, HIV, haemolytic anemia, leukemia, lymphoma, endocarditis, thalassaemia , sickle cell, myelofi brosis, sarcoid, amyloidosis, malaria, leishmaniasis Hepatosplenomeg aly hepatitis, EBV, CMV, chronic liver disease, leukemia, lymphoma, myelofi brosis, amyloid osis _OHFP.indb 131 _OHFP.indb 131 30/05/2014 16:17 30/05/2014 16:17 132 CHAPTER 3 History and examination Neurological History Presenting complaint onset, duration, course (improving, worsening, relapsing \200 \223remitting), aggravating or alleviating factors, change with time of day, trauma. Symptoms headache, pain, numbness, tingling, weakness, tremor, twitching, abnormal movement s, loss of consciousness, seizures, abnormal smells, vision (loss, diplopia, fl ashing ligh ts), hearing, swal- lowing, speech, balance, vertigo, nausea, vomiting, coordination, urina ry incontinence or retention, impotence, fecal incontinence, constipation, personality, mem ory, language, visuospatial skills, change in intellect. Corroborating history in many neurological conditions the patient may not be able to descri be all the symptoms, eg seizure; try to get a history from a witness or family member. Past medical history similar episodes, meningitis, migraines, strokes, sei- zures, heart pr oblems, hypertension, DM, psychiatric problems. Drug history neurological drugs (eg antiepi leptics, Parkinson s medications), psychiatric drugs (eg antipsychotics, antidepressants), all others (especially cardiac and hypoglycaemic drugs). Family history draw a family tree with all four grandparents and all their children and gra ndchildren, ask specifi cally about learning diffi culties, dis- ability, epilepsy, dementi a, CVAs, psychiatric problems. Social history alcohol, smoking, illicit drugs, occupation, travel abroad, dominant hand. Examination Obs GCS, BP (lying and standing), HR, RR, glucose. General appearance posture, neglect, nutrition, mobility aids. Cognition tested using the Mini-Mental State Exam (b p34 3) or 10-point Abbreviated Mental State Exam (b p341). Meningism photophobia, neck stiff ne ss, Brudzinski \200\231s sign (fl exion of both knees on testing neck stiff ness), Kernig \200\231s sign (hamstring spasm on attempting to straighten the knee with hip and knee fl e xed), straight leg raise (hamstring spasm on passively fl exing the hip). Skin birthmarks, vitiligo, caf -au-lait spots, ash leaf macules, lumps, tufts of hair/dimp les at the base of the spine. See Table 3.7 for cranial nerve examination. OHFP.indb 132 OHFP.indb 132 30/05/2014 16:17 30/05/2014 16:17 133 NEUROLOGICAL Table 3.7 Cranial nerve examination Nerve Function Tests Olfactory Optic (Fig. 3.1) Oculomotor I II Smell Vision Rarely tested Visual acuity, visual fi elds, pupil refl exes, fundoscopy Eye movements, pup il refl exes III Eye movements, lift the eyelid, pupil constriction Superior oblique Sensation to face, move ment of jaw muscles Lateral rectus muscle Facial muscle movement, taste (anterior 2/3rd), s alivary and lacrimal glands, stapedius muscle Trochlear Trigeminal IV V Move eye down and out Facial sensation, jaw power, corneal refl ex Abducens Facial VI VII Move eye laterally Facial power Vestibulo- cochlear VIII Hearing and balance Whispering numbers, Weber \200\231s (forehead), Rinne \200\231s (behind ear) Saying \200 \230Ahh \200\231, swallow, gag refl ex Glosso- pharyngeal IX Taste (posterior 1/3rd), parotid gland, sensation of pharynx, nasopharynx, middle ear Sensa tion of pharynx and larynx, movement of palate, pharynx, larynx Saying \200\230Ahh \200\231 (deviates away from defect), cough, swallow, speech, gag refl ex Shrug shoulders, turn head Vagus X Accessory XI Movement of sternomastoid and trapezius Hypoglossal XII Movement of tongue Stick tongue out (deviates towards defect), speech Visual field Left Right Normal fields Normal Right Left 1 Unilateral vision loss Optic nerve 1 2 Bitemporal hemianopia Optic chiasma 3 Homonymous hemianopia 4 2 3 Lateral geniculate nucleus Upper quadrantanopia 4 5 Lower quadrantanopia 5 Optic radiation 6 Homonymous hemianopia (with central sparing) 6 Visual cortex Fig. 3.1 Optic pathways and eff ect of a lesion on the visual fi elds at various locations. _OHFP.indb 133 _OHFP.indb 133 30/05/2014 16:17 30/05/2014 16:17 134 CHAPTER 3 History and examination Peripheral nerve examination Appearance posture, tremor, muscle wasting, fasciculation, abn ormal movements, facial expression and symmetry, neglect. Hold out hands with palms up and eyes closed; look for drift (pyramidal defect), tremor or involuntary fi nger movement (los s of position sense). Tone tone at wrist, elbow, knee and ankle (increased, decreased, clas p knife, cog-wheeling), clonus at the ankle ( \211 5 beats is abnormal). Power isolate each joint with one hand so that only the muscle group you are testing can be used for the move ment; compare each side (Table 3.8). Table 3.8 Medical Research Council (MRC) grading of muscle power Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 No movement Flicker of movement Movement but not against gravity Weakness but movement agai nst gravity Weakness but movement against resistance Normal power Table 3.9 Root levels of main limb movements Joint Movement Root Joint Movement Root Shoulder Abduction Adduction Flexion Extension Flexion Extension Flexion Extension C5 C5 \200\2237 C5 \200\2236 C7 C7 \200\2238 C7 C8 C7 Hip Flexion Adduction Extension Flexion Extension L1 \200\2232 L2 \200\2233 L5 \200\223S1 L5 \200\223S1 L3 \200\2234 L4 S1 \200\2232 L5 Elbow Knee Wrist Ankle Dorsifl exion Fingers Plantarfl exion Big toe Extension Abduction T1 Re \202 exes deep tendon refl exes comparing each side (Table 3.10), if absent ask the pat ient to clench their teeth (reinforcement); plantar refl exes. Table 3.10 Tendon re \202 exes Grading of tendon re \202 exes Root levels of tendon re \202 exes 0 + ++ +++ ++++ Increased with clonus Absent Present with reinforcement Reduced Normal Increased Root Re \202 ex Root Re \202 ex L3 \200\2234 Bicep C5 \200\2236 Knee Supinator C5 \200 \2236 Ankle S1 \200\2232 Tricep C7 \200\2238 OHFP.indb 134 OHFP.indb 134 30/05/2014 16:17 30/05/2014 16:17 135 NEUROLOGICAL Coordination fi nger \200\223nose, dysdiadochokinesia, tapping, heel \200\223shin. Romberg \200\231s tested with patient standing with eyes open then closed, posi- tive if more unbal anced with eyes closed; suggests sensory ataxia. Sensation pinprick, light touch, vibration, joint position; the spinal dermat- omes of the front and back are shown in Fig. 3.2 and spinal tracts on b p136. Front Back V C2 C2 C3 C3 C4 C4 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T3 T5 C5 C5 T6 T7 T8 T9 T10 T11 T12 L1 T2 T2 C6 T1 T1 L1 C6 L2 S4 S5 C8 S2,S3 C7 C7 C8 S3 L3 L2 S2 L3 L3 L4 L5 L4 S1 L5 S1 L5 Fig. 3.2 Dermatomes of the front (L) and back (R). Nerves of the hand See Table 3.11 and Fig. 3.3. Table 3.11 Innervation of hand movements Movement Finger abduction and adduction Thumb oppo sition and abduction Finger extension Nerve Ulnar Median Radial Palmar Dorsal Median Ulnar Radial Median Fig. 3.3 Sensation of the hand. _OHFP.indb 135 _OHFP.indb 135 30/05/2014 16:17 30/05/2014 16:17 136 CHAPTER 3 History and examination Table 3.12 Gait examination Gait Description Cause Antalgic Painful gait, limping, short weight-bearing on painful side Unable to lift legs despite nor mal power, magnetic steps/stuck to fl oor Uncoordinated, wide-based, unsteady (as if drunk) , worse with eyes shut if sensory A shuffl ing gait with accelerating steps Mechanical injury, sciatica Hydrocephalus, frontal lesions Cerebellar, sensory Apraxic Ataxic Festinating Hemiparetic Knee extended, hip circumducts and drags leg; elbow may be fl exed up Myopathic Waddling, leaning back, abdomen sticking Parkinson \200\231s Hemiplegia, eg CVA Proximal myopathy out Short, shuffl ed steps, stooped, no arm swing Restricted knee and hip movements, slow, shuffl ing, \200\230wading through water \200\231 High steps with foot slapping, \200\230 foot drop \200\231 Shuffl ing Parkinson \200\231s Spastic Pyramidal tract lesion eg MS Peripheral neuropathy Steppage Table 3.13 Spinal tracts and anatomy Tract Modality Crosses (decussates) at Lateral corticospinal (pyramidal) Anterior corticospinal Motor Posterior columns (dorsal) S pinothalamic Motor Medulla Level of exit of the cord Medulla Light touch, vibration, position Hard touch, pain, temperature Level of entry to the cord Central canal Posterior column Lateral corticospinal tract Dorsal root (sensory) Dorsal root ganglion Spinal nerve Ventral root (motor) Spinothalamic tract Anterior corticospinal tract Motor Sensory Fig. 3.4 Cross-section of the spinal cord showing spinal tracts. OHFP.indb 136 OHFP.indb 136 30/05/2014 16:17 30/05/2014 16:17 137 ENDOCRINE Endocrine History Symptoms weight loss, weight gain, appetite, sweating, heat/cold intol- erance, tre mor, weakness, tiredness, dizziness, hirsuitism, joint pain/ swelling, change in appearance (skin, hair, nails, face, eyes), change in clothes/shoe/hat size, altered sensation, ulcer s, visual problems. Cardiorespiratory features chest pain, breathlessness, palpitations, sleep apnoea. GI/urinary features diarrhea, constipation, nausea, vomiting, abdominal pain, thirst, polyu ria. Reproductive features menstrual irregularities, infertility, gynaecomastia, galactorrhoea, impotence. Psychiatric features anxiety, mood changes, memory problems. Eye features blurre d vision, visual fi eld defects, bulging eyes. Past medical history thyroid surgery, stroke , heart failure, liver failure, renal artery stenosis, renal failure, adrenal surgery, brai n surgery. Drug history steroids, diuretics, OCP, HRT, levothyroxine, insulin. Family history DM, thyr oid disease, pituitary tumors. Examination (lying at 45 ) General inspection body habitus, \200\230buff alo hump \200 \231, facial appearance ( \200\230moon face \200\231), striae, bruising, muscle wasting, hy perpigmentation, coarse skin, prominent jaw and brow ridge, goiter, gynaecomastia, hirsuiti sm, acanthosis nigricans, vitiligo, acne, necrobiosis lipoidica, pre- tibial myxoedema. Hands temperature, sweating, size, tremor. Eyes lid lag, proptosis, exophthalmos, bitempora l hemianopia, cranial nerve III, IV, or VI palsy, fundoscopy. Neck goiter, thyroid lumps. Cardiorespiratory idHR, idBP, postural hypotension, irregular p ulse, peripheral oedema, bibasal crackles (LVF). Neurological cranial nerve III/IV/VI palsy , peripheral neuropathy, slow relaxing refl exes, weakness (myopathy). Other joints, skin, genitalia, fundoscopy, urine analysis, U+E, early morning cortisol, TFT s, short Synacthen test (b p571), GTT \200\223 more specialist tests on advice from an e ndocrinologist. _OHFP.indb 137 _OHFP.indb 137 30/05/2014 16:17 30/05/2014 16:17 138 CHAPTER 3 History and examination Skin History Presenting skin complaint timing how long present for, sudden or gradual onset, get ting better or worse; location original site and subsequent sites aff ected; symptoms itch (localized or generalized), pain, burning, bleeding, weeping; exacerbating factors dietary components, drugs, sunlight (seasonal variability), pet dander, night-time, water; relievin g factors emollient cream, topical/systemic steroids. Current health anorexia, diarrhea, fe ver, headache, fatigue, weight loss, depression, sore throat, joint pain. Past medical history previous skin disease, DM, BD, asthma/atopy, varicose veins, periphera l arterial disease, cardiac problems, endocrine disease, neurological problems, ulcers, tra uma, sarcoid, porphyria, SLE, malig- nancy, sensitivity of skin to sun exposure, lifelong h istory of sun expo- sure or use of sun beds. Drug history dermatological agents being used at present and their eff ects, previous drugs used and their eff ects, oral and topical steroids, other drugs being taken, drug allergie s. Allergy hayfever, pet dander, dust mite etc. Occupational history current and previous j obs and eff ect of work upon skin, exposure to chemicals; hobbies and recreational activiti es. Family history anyone else in the family aff ected; need to diff erentiate inherited pathol ogy versus infectious pathology. Travel history recent foreign travel and relationship of any travel to skin disease \200 \223 vaccinations/prophylaxis taken for foreign travel. Function restricted actions, eff ect on life, mobility, occupation, dominant hand, hobbies/ sports, smoking, social support. Examination The whole body should be examined in good natural light; patients complaining o f a rash on their arm may well have other tell-tale signs elsewhere on the body. Don \200 \231t be afraid to ask patients to strip, but remember to have a chaperone present and to e xplain why you are looking. 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.