medicine compents of history taking 2014
DESCRIPTION
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COMPONENTS OF HISTORY
BYDaniel Eshetu
Aim of this course
To understand why medical history
taking is important
To understand different
frameworks and apply them
Basic clinical skills
A skill is something you do
It is not enough to “know” how to do
something; you have to be able to do it
Basic clinical skills are
-Medical interviewing
-Physical examination and
-Communication ( history taking,explain
diagnosis to a patient ,telling your
peer about a “case”-)
INTRODUCTION
• complete medical evaluation includes
• medical history• physical examination• appropriate laboratory or imaging
studies• analysis of data • Diagnoses• treatment plan
A medical record
is a legal document in many jurisdictions
Factors in establishing rapport
• Introduce yourself in a warm, friendly
manner
• Maintain good eye contact
• Listen attentively
• Facilitate verbally and non-verbally
• Touch patients appropriately
• Discuss patients’ personal concerns
Practice of Medicine combines
*SCIENCE as the evidence base
and
*ART in the application of this
medical knowledge
The “ Classic” History Taking Sequence
• The order are :-
• Identification• Previous Admission• Chief Complaints• History of Present Illness• Past Illness• Functional Inquiry ( System Review)• Personal History• Family History• Physical Examination• Summary• Differential Diagnosis
Identification
• Name (preferably with the name of the grandparent)
• Age
• Sex
• Occupation
• Address
• Hospital number
NASOAH
Previous Admission
• List of hospitalization in the order they occurred
• Specify the date
• Name and location of the hospital
• Disease that led to admission
• Outcome as briefly as is possible, e.g.
1990 (EC). Menilik II Hospital, Addis
Ababa. Bleeding duodenal ulcer.
Discharged symptom free after
transfusion of 2 units of blood.
1992 (EC). TAH, Addis Ababa. Newly
diagnosed Diabetes Mellitus.
Discharged symptom free with daily
dose oh human insulin30 unit SC.
1999 (EC). St. Paul’s’ Hospital. Addis
Ababa. DKA. Discharged symptom free
with daily of human insulin 45 units sc
in divided dose.
Chief Complaints
• Those signs and symptoms which prompted the patient to seek medical advice
• Duration of each sign and symptom
• More than one complaint, they should be listed in the order of occurrence.
History of the Present Illness
• Chronological order of events of symptoms and further clarification of each symptom
• Follow in chronological order as the following
Date of onset
It is often useful to start the History ofthe Present Illness with the phrase“The patient was perfectly welluntil …”
Development of the signs andsymptoms, expressed as chiefcomplaints, should be traced indetail to the present time.
Mode of onset, course and duration
• sign or symptom indicate whether the onset was abrupt or gradual
• intermittent or persistent
• short lived or constant
• steady or increasing in severity
• find out if other signs and symptoms have developed
Character and Location
Clear description of the complaint is necessary
For example, an abdominal pain may be burning, aching, dull or sharp in character
Find out if there are factors or conditions that relieve or aggravate
Exacerbations and Remissions
• Conditions which exacerbate and remit
Eg.
Shortness of breath is exacerbate on exersiseand remit at rest
Effect of Treatment
Patients may have taken drugs or other forms oftherapy
Such drugs may not have been taken properlyMay have adverse effects by themselvesMay have worsened or alleviated the symptomsMay have had no effect whatsoever exceptTreatment for disease other than the one under
complaint should also be fully recorded.
“Negative-positive” Statements
Very significant aspect of the History ofPresent Illness
Conducted thoroughly as possible with aview to constructing a differentialdiagnosis
Negative statement may be as importantas a positive statement.
Statements are expressed in terms of signsand symptoms but not diseases.
Colour, Strength and Weight
• Last paragraph of the History of the Present Illness should state how the patient came to the hospital
–on a stretcher, walking, urged by his friends’ advice
• Mention of any colour, strength or weight changes
Past Illness
• Listing of illness unrelated to the present illness, experienced in the past
• Including childhood diseases
• Serious injuries and surgery not requiring hospitalization
• Mention of each disease with an approximate date, severity, duration, complications and sequel (consequences) is essential
Functional Inquiry (system Review) Detailed account of signs and symptoms
referable to each system of the bodyAdvantages in obtaing and recording
First, it gives a clear understanding of the history of the present illnessSecondly, it is a double check on the history of the present illnessThirdly, it will permit the examiner to group signs and symptoms that need to be considered with the present complaintFourthly, it will guide the examiner to concentrate on specific systems during the physical examination
HEENT =Head, Ears, Eyes, Nose, Mouth
and Throat
Head : Headache, injury
Ears: Pain or earache, deafness,
discharge, vertigo, tinnitus.
Eyes: Disturbance of vision, pain in the
eyes or orbit, eye-strain,
lacrimation, photophobia, itching.
Nose: Frequent head colds, epistaxis,
discharge, hay-fever, sinusitis.
Mouth and throat: Teeth (dental hygiene),
bleeding gums, sore tongue,tonsillectomy,
sore throat,
Glands
Enlarged glands
Lumps in the breasts, discharge
from the nipple
Goiter with or without heat or cold
intolerance
Undescended or swollen testicles.
Respiratory system
Cough
Expectoration (amount, colour,
odour)
Haemoptysis
Chest pain
Shortness of breath
Wheezing or asthma
Cyanosis.
Cardiovascular system
Dyspnoea (degree of exercise
tolerance)
Palpitation
Orthopnoea (number of pillows
required)
Paroxysmal nocturnal dyspnoea
Swelling of the feet
Chest pain ( with character, location
and radiation)
Syncope
Stridor
Hypertension
Gastrointestinal system
Appetite
Nausea
Vomiting
Dysphagia
Food idiosyncrasy
Heart burn
Abdominal pain
Bowel habits
Jaundice
Bloody, tarry or clay-colored stools
Hemorrhoids
Genitourinary system
Flank pain (steady, colicky, etc.)
Frequency of urine (express the day to
night ratio as D/N= ----) Dysuria, urgency,
hesitancy, dribbling, haematuria, pyuria,
incontinence
Veneral disease
Menstrual history : Record as
“menarche/interval between
periods/duration of flow/amount of flow”
,e.g. 14/28/5 profuse, moderate or normal
menopause (mention if there are
postmenopausal symptoms)
Integumentary system (skin, hair
and nails)
Dry or moist skin
Rashes
Ulcers
Urticaria
Hair distribution
Pigmentary changes
Changes in fingernails
Allergy
Infantile eczema
Drug sensitivity
Urticaria
Hayfever
Asthma
Serum sensitivity
Locomotor system (musculo-
skeletal system)
Bony deformities
Joint pain or swelling
Limping
Loss of function of limbs or joints
Muscle weakness or wasting
Leg-swelling like elephantiasis.
Central nervous system (CNS)
Poor memory
Lack of orientation
Seizures
Vertigo
Diplopia
Anesthesia
Hyperesthesia
Insomnia
nervous breakdown
Personal History • Record the personal history as follows:• Early development: place of birth and early
homes, childhood development, health and activities, social and economic status.
• Education: School history, achievements and failures.
• Social activities: Recreation and other activities• Work record: Age begun, type of work, number of
jobs (mention success or failure regarding shift of jobs), industrial hazards and exposures, present work.
• Environment: living conditions.• Habits: Dietary, alcohol, tobacco,drugs,herbs
(including anthelmintics).• Marital status: Health of wife (or husband),
adjustment, number of childrenand their health.
Family History
• Father and mother: Age ,health, date and cause of death.
• Siblings: List with ages, health
( if dead, mention cause of death)
• Family disease: Tuberculosis, diabetes mellitus, hypertensive disorders, migraine.
Physical Examination
The physical examination is the examination of the patient looking for signs of disease
• 'Symptoms' are what the patient volunteers
• 'Signs' are what the physician detects by examination).
Success in recording complete
physical findings depends on a
step-by-step and systematic
examination
Depending on the system
involved or suspected, negative
reports are as significant as
positive ones
The four cardinal methods
Inspection
Palpation
Percussion
Auscultation
Should be strictly observed
General appearance
Severity and acuteness of illness
Physique
Constitution
Nutritional state
Emotional state
facial expression
Colour change
Vital Signs
• a.Temperature
• Temperature can be measured is several different ways:
• Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C)
• Axillary with a glass or electronic thermometer (normal 97.6F/36.3C)
• Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)
• Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)
• Of these, axillary is the least and rectal is the most accurate.
b.Respiration
Without letting go of the patients wrist
begin to observe the patient's
breathing. Is it normal or labored?
Count breaths for 1min ad record
breaths per minute
In adults, normal resting respiratory
rate is between 14-20 breaths/minute
Rapid respiration is called tachypnea
c.Pulse
Note whether the pulse is regular or irregular:
measure rate accurately
Count for a full minute
Record the rate and rhythm.
A normal adult heart rate is between 60 and 100
beats per minute
A pulse greater than 100 beats/minute is defined
to be tachycardia
Pulse less than 60 beats/minute is defined to be
bradycardia
d.Blood Pressure
Palpate the radial pulse and inflate the cuff until
the pulse disappears. This is a rough estimate of
the systolic pressure
Release the pressure slowly, no greater than 5
mmHg per second.
Continue to lower the pressure until the sounds
muffle and disappear. This is the diastolic
pressure
Record the blood pressure as systolic over
diastolic ("120/70" for example )
Head, Ears, Eye, Nose and Mouth and Throat
• Head
• Look for scars, lumps, rashes, hair loss, or other lesions
• Look for facial asymmetry, involuntary movements, or edema.
• Palpate to identify any areas of tenderness or deformity.
Ears
Inspect the auricles and move them around
gently. Ask the patient if this is painful.
Palpate the mastoid process for tenderness
or deformity.
Insert the otoscope inspect the ear canal
and middle ear structures noting any
redness, drainage, or deformity.
Repeat for the other ear.
Eyes
Inspect lid lag, ptosis, exophthalmoses,
lacrimation, peri-orbital edema and
nystabmus
Inspect conjunctival pallor, hemorrhage,
scleral colour and pterygia
Examine the fundi by using ophthalmoscope
Nose
Tilt the patient's head back slightly.
Ask them to hold their breath for the
next few seconds.
Insert the otoscope into the nostril,
avoiding contact with the septum.
Inspect the visible nasal structures
and note any swelling, redness,
drainage, or deformity.
Repeat for the other side.
Throat
Ask the patient to open their mouth.
Using a wooden tongue blade and a good
light source, inspect the inside of the
patients mouth including the buccal folds
and under the tougue
Note any ulcers, white patches
(leucoplakia), or other lesions.
Inspect the posterior oropharynx by
depressing the tongue and asking the
patient to say "Ah." Note any tonsilar
enlargement, redness, or discharge.
Glands
• Inspect the neck for asymmetry, scars, or other lesions.
• Palpate the neck to detect areas of tenderness, deformity, or masses
Lymph Nodes
Systematically palpate with the pads of your
index and middle fingers for the various lymph
node groups.
Preauricular - In front of the ear
Postauricular - Behind the ear
Occipital - At the base of the skull
Tonsillar - At the angle of the jaw
Submandibular - Under the jaw on the side
Submental - Under the jaw in the midline
Superficial (Anterior) Cervical - Over and in
front of the sternomastoid muscle
Supraclavicular - In the angle of the
sternomastoid and the clavicle
Axillary, ingunal
Note the size and location of any palpable
nodes and whether they were soft or hard,
non-tender or tender, and mobile or fixed.
Thyroid Gland
Inspect the neck looking for the thyroid
gland. Note whether it is visible and
symmetrical
A visibly enlarged thyroid gland is called a
goiter.
Move to a position behind the patient.
Move laterally from the midline while
palpating for the lobes of the thyroid
The normal gland is often not palpable
Note the size, symmetry, and position of the
lobes, as well as the presence of any nodules
Respiratory System
• General Considerations• The patient must be properly undressed and
gowned for this examination • Ideally the patient should be sitting on the end of
an exam table • The examination room must be quiet to perform
adequate percussion and auscultation • Observe the patient for general signs of
respiratory disease (finger clubbing, cyanosis, air hunger, etc.)
• Try to visualize the underlying anatomy as you examine the patient
Inspection
Observe the rate, rhythm, depth, and
effort of breathing. Note whether the
expiratory phase is prolonged
Listen for obvious abnormal sounds
with breathing such as wheezes
Observe for retractions and use of
accessory muscles (sternomastoids,
abdominals)
Observe the chest for asymmetry,
deformity, or increased anterior-
posterior (AP) diameter
Palpation
Identify any areas of tenderness or
deformity by palpating the ribs and
sternum
Assess expansion and symmetry of
the chest by placing your hands on
the patient's back, thumbs
together at the midline, and ask
them to breath deeply.
Check for tactile fremitus
Percussion
Proper Technique
Proper Technique
Hyperextend the middle finger of
one hand and place the distal
interphalangeal joint firmly against
the patient's chest
With the end (not the pad) of the
opposite middle finger, use a quick
flick of the wrist to strike first finger
Categorize what you hear as normal,
dull, or hyperresonant
Percuss from side to side and top to
bottom
Compare one side to the other
looking for asymmetry
Note the location and quality of the
percussion sounds you hear
Find the level of the diaphragmatic
dullness on both sides
Ask the patient to inspire deeply
The level of dullness (diaphragmatic
excursion) should go down 3-5cm
symmetrically
Auscultation
Use the diaphragm of the
stethoscope to auscultate breath
sounds.
Auscultate from side to side and top
to bottom
Compare one side to the other looking
for asymmetry
Normally Vesicular breath sounds and
Bronchovesicular
Note the location and quality of the
sounds you hear
Cardiovascular Examination
• General Considerations
• The patient must be properly undressed and in a gown for this examination
• The examination room must be quiet to perform adequate auscultation
• Observe the patient for general signs of cardiovascular disease (finger clubbing, cyanosis, edema, etc.)
Arterial Pulses
Rate and Rhythm
Note whether the pulse is regular or
irregular.
Count for a full minute and record
Record the rate and rhythm.
Volume
Character
Condition of Vessel Wall
Pulse Classification in Adults (At Rest)
Normal Bradycardia Tachycardia
60 to 100 bpm less than 60 bpm more than 100
RegularRegularly
IrregularIrregularly Irregular
Evenly spaced beats,
may vary slightly
with respiration
Regular pattern
overall with
"skipped" beats
Chaotic, no real pattern,
very difficult to measure
rate accurately [2]
Blood Pressure
Record the blood pressure
as systolic over diastolic
(120/70)
Blood pressure should be
taken in both arms on the
first encounter
Jugular Venous Pressure
Position the patient supine with the head of the
table elevated 5 degrees
Adjust the angle of table elevation to bring out
the venous pulsation
Identify the highest point of pulsation
Using a horizontal line from this point, measure
vertically from the sternal angle
This measurement should be less than 4 cm in a
normal healthy adult
Precordium
Inspection
Active or quite
precordium
Location of apical
impulse
Deformity
Palpation
Palpate for the point of maximal impulse (PMI
or apical pulse). It is normally located in the
4th or 5th intercostal space just medial to the
midclavicular line and is less than the size of a
quarter.
Parasternal heave
Thrill (systolic, diastolic, both)
Pericardial friction rub
Percussion
Cardiac outline
Auscultation
Listen with the diaphragm at the right 2nd
interspace near the sternum (aortic area)
Listen with the diaphragm at the left 2nd
interspace near the sternum (pulmonic
area)
Listen with the diaphragm at the left 3rd,
4th, and 5th interspaces near the sternum
(tricuspid area)
Listen with the diaphragm at the apex (PMI)
(mitral area)
Record S1, S2, (S3), (S4), as well as the
grade and configuration of any murmurs
Added heart Sounds, Gallop,opening
Snap,pericardial friction rub,murmur
Murmur Grades
Grade Volume Thrill
1/6very faint, only heard with optimal
conditionsno
2/6 loud enough to be obvious no
3/6 louder than grade 2 no
4/6 louder than grade 3 yes
5/6heard with the stethoscope partially off the
chestyes
6/6heard with the stethoscope completely off
the chestyes
Gastrointestinal System
• General Considerations
• The patient should have an empty bladder. • The patient should be lying supine on the
exam table and appropriately draped. • The examination room must be quiet to
perform adequate auscultation and percussion.
• Watch the patient's face for signs of discomfort during the examination.
• Consider the inguinal/rectal examination in males. Consider the pelvic/rectal examination in females
Use the appropriate terminology to locate your
findings:
Right Upper
Quadrant (RUQ)
Right Lower
Quadrant (RLQ)
Left Upper
Quadrant (LUQ)
Left Lower
Quadrant (LLQ)
Midline:
Epigastric
Periumbilical
Suprapubic
Inspection
Look for scars, striae, hernias,
vascular changes, lesions, or
rashes
Look for movement associated
with peristalsis or pulsations
Note the abdominal contour
Is it flat, scaphoid, or
protuberant?
Palpation
General Palpation
Begin with light palpation
At this point you are mostly looking for
areas of tenderness
The most sensitive indicator of
tenderness is the patient's facial
expression (so watch the patient's
face, not your hands)
Proceed to deep palpation after
surveying the abdomen lightly
Try to identify abdominal masses or
areas of deep tenderness
Palpation of the Liver
Place your fingers just below the right
costal margin and press firmly
Ask the patient to take a deep breath
You may feel the edge of the liver
press against your fingers
Or it may slide under your hand as the
patient exhales
A normal liver is not tender
Palpation of the Spleen
Use your left hand to lift the lower
rib cage and flank
Press down just below the left costal
margin with your right hand
Ask the patient to take a deep breath
The spleen is not normally palpable
on most individuals
Percussion
Percussion
Percuss in all four quadrants using proper technique
Categorize what you hear as tympanitic or dull
Tympany is normally present over most of the
abdomen in the supine position
Unusual dullness may be a clue to an underlying
abdominal mass
Liver Span
Percuss downward from the chest in the right
midclavicular line until you detect the top edge of liver
dullness
Percuss upward from the abdomen in the same line
until you detect the bottom edge of liver dullness
Measure the liver span between these two points
This measurement should be 6-12 cm in a normal
adult
Splenic Dullness
Percuss the lowest costal interspace in
the left anterior axillary line
This area is normally tympanitic
Ask the patient to take a deep breath
and percuss this area again
Dullness in this area is a sign of splenic
enlargement
Auscultation
Place the diaphragm of your
stethoscope lightly on the abdomen
Listen for bowel sounds
Are they normal, increased,
decreased, or absent?
Listen for bruits over the renal
arteries, iliac arteries, and aorta
Genitourinary System
Costo-vertebral angle and suprapubictenderness,size, location and mobility of kidneys
In male : scrotom, and urethral orificeTestes-- >size, tumors, descent
In female : vaginal dischargeLabia majoria and minora-- >
choncroid,condylomata,etc
Integumentary System
• Skin• Texture, dry, moist and temperature• Purpura, rashes, ulcers, urticaria hypo-
or hyper-pigmentation• Hair• Sparse, boldness, alopecia and texture• Nails• Colour, shape capillary pulse and
splinter hemorrhages
Locomotor System
• Inspection
• Look for scars, rashes, or other lesions
• Look for asymmetry, deformity, or atrophy
• Always compare with the other side
• Spine Scoliosis, Kyphosis, Gibbus
Palpation
Examine each major joint and muscle group in
turn
Identify any areas of tenderness
Identify any areas of deformity, dislocation
Always compare with the other side
Spine tenderness on percussion or on pressure
Range of Motion
Start by asking the patient to move through an
active range of motion (joints moved by patient)
Proceed to passive range of motion (joints moved
by examiner) if active range of motion is
abnormal
Specific Joints
Fingers ; Thumb ; Wrist ; Forearm ;
Hip ; Knee
Ankle ; Foot ;
Spine
Nervous System
• General Considerations
• Always consider left to right symmetry • Consider central vs. peripheral deficits • Organize your thinking into these categories:
– Mental Status – Cranial Nerves – Motor – Coordination and Gait – Reflexes – Sensory
Mental Status
The Mini Mental Status Examination is
a useful screening tool
Orientation in person, place and time,
memory ( past ,present )
Level of consciousness Intelligence,
mood, attention speech, hallucination
and delusions
Level of education, cooperation with
the examiner
Cranial Nerves
• I – Olfactory
• II - Optic• Examine the Optic Fundi • Test Visual Acuity ScreenVisual Fields by Confrontation • Test Pupillary Reactions to Light • Test Pupillary Reactions to Light
III - Oculomotor
Observe for Ptosis
Test Extraocular Movements
Test Pupillary Reactions to Light
IV - Trochlear
Test Extraocular Movements (Inward
and Down Movement )
VI - Abducens
Test Extraocular Movements (Lateral
Movement)
V – Trigeminal
Test Temporal and Masseter Muscle
Test the Three Divisions for Pain Sensation
Test the Corneal Reflex
VII - Facial
Observe for Any Facial Droop or Asymmetry
Ask Patient to do the following, note any
lag, weakness, or assymetry:
Raise eyebrows
Close both eyes to resistance
Smile, Frown, Show teeth, Puff out
cheeks
Test the Corneal Reflex
VIII - Acoustic
Screen Hearing
Test for Lateralization
Compare Air and Bone Conduction (Rinne)
IX – Glossopharyngeal & X - Vagus
Listen to the patient's voice, is it hoarse or nasal?
Ask Patient to Swallow
Ask Patient to Say "Ah"
Watch the movements of the soft palate and
the pharynx.
Test Gag Reflex (Unconscious/Uncooperative
Patient)
Stimulate the back of the throat on each side.
It is normal to gag after each stimulus
XI - Accessory
From behind, look for atrophy or assymetry of the
trapezius muscles
Ask patient to shrug shoulders against resistance.
Ask patient to turn their head against resistance.
Watch and palpate the sternomastoid muscle on
the opposite side
XII - Hypoglossal
Listen to the articulation of the patient's words.
Observe the tongue as it lies in the mouth
Ask patient to:
Protrude tongue
Move tongue from side to side
Motor
Inspection
Involuntary Movements
Muscle Symmetry, Left to Right
Proximal vs. Distal, Atrophy
Pay particular attention to the hands, shoulders,
and thighs
Gait
Muscle Tone
Ask the patient to relax
Flex and extend the patient's fingers, wrist, and
elbow
Flex and extend patient's ankle and knee.
There is normally a small, continuous resistance to
passive movement
Observe for decreased (flaccid) or increased
(rigid/spastic) tone
Muscle Strength
Test strength by having the
patient move against your
resistance
Always compare one side to the
other
Grade strength on a scale from 0
to 5 "out of five":
Grading Motor Strength
Grade Description
0/5 No muscle movement
1/5Visible muscle movement, but no movement at
the joint
2/5 Movement at the joint, but not against gravity
3/5Movement against gravity, but not against added
resistance
4/5 Movement against resistance, but less than normal
5/5 Normal strength
Coordination and Gait
Rapid Alternating Movements
Ask the patient to strike one hand on
the thigh, raise the hand, turn it over,
and then strike it back down as fast as
possible
Ask the patient to tap the distal thumb
with the tip of the index finger as fast
as possible
Ask the patient to tap your hand with
the ball of each foot as fast as
possible
Point-to-Point Movements
Ask the patient to touch your index finger
and their nose alternately several times
Move your finger about as the patient
performs this task
Hold your finger still so that the patient can
touch it with one arm and finger
outstretched
Ask the patient to move their arm and
return to your finger with their eyes closed
Ask the patient to place one heel on the
opposite knee and run it down the shin to
the big toe
Repeat with the patient's eyes closed
Romberg
Be prepared to catch the patient if
they are unstable
Ask the patient to stand with the feet
together and eyes closed for 5-10
seconds without support
The test is said to be positive if the
patient becomes unstable (indicating a
vestibular or proprioceptive problem)
Gait
Ask the patient to:
Walk across the room, turn and come
back
Walk heel-to-toe in a straight line
Walk on their toes in a straight line
Walk on their heels in a straight line
Hop in place on each foot
Do a shallow knee bend
Rise from a sitting position
Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned
properly before starting
Reflex response depends on the force of
your stimulus. Use no more force than you
need to provoke a definite response
Reflexes can be reinforced by having the
patient perform isometric contraction of
other muscles (clenched teeth)
Reflexes should be graded on a 0 to 4 "plus"
scale:
Tendon Reflex Grading Scale
Grade Description
0 Absent
1+ or + Hypoactive
2+ or ++ "Normal"
3+ or +++ Hyperactive without clonus
4+ or ++++ Hyperactive with clonus
Biceps (C5, C6)
Triceps (C6, C7)
Brachioradialis (C5, C6)
Abdominal (T8, T9, T10, T11, T12)
Knee (L2, L3, L4)
Ankle (S1, S2)
Clonus
If the reflexes seem hyperactive,
test for ankle clonus:
Support the knee in a partly flexed
position
With the patient relaxed, quickly
dorsiflex the foot
Observe for rhythmic oscillations
Plantar Response
(Babinski)
Stroke the lateral aspect of the sole of each foot
with the end of a reflex hammer or key.
Note movement of the toes, normally flexion
(withdrawal)
Extension of the big toe with fanning of the other
toes is abnormal. This is referred to as a positive
Babinski
Sensory
General
Explain each test before you do it.
Unless otherwise specified, the patient's
eyes should be closed during the actual
testing
Compare symmetrical areas on the two
sides of the body
Also compare distal and proximal areas of
the extremities
When you detect an area of sensory loss
map out its boundaries in detail
Vibration
Subjective Light Touch
Position Sense
Pain
Temperature
Light Touch
Discrimination
Summary
Subjective. This will include those
relevant points obtained from the Chief
Complaints, the History of the Present
Illness, the Functional Inquiry, Personal
and Family History.
Objective. This will include only the
positive physical findings.
Differential Diagnosis
The different possible diagnosis should be
listed in the order of priorities, i.e. the
most likely diagnosis on top of the list and
the least likely diagnosis at the end of the
list
The differential diagnosis must include
only those conditions that are relevant to
the presenting problem(s)
Discussion of Differential Diagnosis
A logical approach to the discussion of a
given list of possible diagnoses will
require a careful analysis of the history,
the physical findings, and the appropriate
investigation relevant to the presenting
problem(s) before arriving at a plausible
final diagnosis
Discussion of the differential diagnosis
must start from the bottom of the list
This will permit a step by step exclusion
of the least likely conditions
The diagnosis must be confirmed by
laboratory and other diagnostic tests and
procedure
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