429 History Taking and Physical Examination Booklet 2nd Edition 2013 (1)

Second Edition 2013

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‫إوطلقىا مه حيث وقف آخرون‪..‬‬ ‫عشىا أياما كالتي تعيشىن‪..‬‬ ‫فشهدوا حاجات للتطىير والتجديد‪ ..‬وإضافة ما يفيد ‪..‬‬ ‫فكان هذا العمل مه أجلكم ‪..‬‬ ‫شكرا لألطباء الفضالء العامليه على ملزمة ‪ ، 424‬والتي بىي على أساسها هذا العمل‪:‬‬

‫د‪ .‬دعاء امبلوي‪ ،‬د‪ .‬هما املكيزني‪ ،‬د‪ .‬هدى املغريب‪ ،‬د‪ .‬عبدامعزيز امكهنل‪ ،‬د‪ .‬مساعد امحلزة‬ ‫‪………………………….‬‬

‫إن تجدعيبا فسد الخلال * * * جل مه ال عيب فيه وعال‬

‫إن كان مه مالحظة أو إقتراح ورجىا التىاصل على البريد االلكترووي‪:‬‬ ‫‪[email protected]‬‬

‫تمىياتىا لكم بالتىفيق‪..‬‬ ‫فريق عمل ‪:424‬‬

‫اميان امرش يدي‬ ‫بدراء احملارب‬ ‫بدور امقدره‬ ‫رهام احلنايك‬ ‫ساره بن حسني‬ ‫شوق امعقيل‬ ‫فاطمة اخلرشم‬ ‫عفاف امرخيص‬ ‫هوف امزهدي‬

‫‪1‬‬

NOTE: This is the second edition of this booklet. Spelling mistakes have been corrected, some figures and definitions have been added for a better understanding.. (:

Contents General Structure of history taking and general examination

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History and Examination of the Cardiovascular System

15

History and Examination of the Respiratory System

30

History and Examination of the Gastrointestinal System

45

History and Examination of the Nervous System

59

History and Examination of the Genitourinary System

91

History and Examination of the Rheumatological System

99

History and Examination of the Endocrine System

113

History and Examination of the Hematological System

120

How to Report your Examination?

127

Frequently Asked Questions& Cranial Nerves

133

References

151

Prepare for a new Challenge.. Listen, see, be involved & try yourself.. Confidence comes from the continual repetition of certain activities..

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General Structure of History Taking, and General Examination:  History Taking: 1. Personal data 2. Chief complaint 3. History of the presenting illness 4. Past history 5. Medication history 6. Blood transfusion 7. Allergies 8. Menstrual history 9. Family history 10.Social history 11.Systemic review 12.Summary  General Examination: 1. General appearance 2. Vital signs 3. The hand 4. The head 5. The neck 6. Lymph nodes 7. Lower limbs 8. The back  Important Analysis

Do Not Fear Mistakes

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 History taking: Important Points to Put in Your Mind:      

Say: ‫السالم عليكن ورحوة هللا وبركاته‬ Introduce yourself to the patient as a student doctor. Take the permission. Close the curtain. Sit down In order to obtain a good history, the clinician must:

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Establish a good relationship. Interview in a logical manner. Listen carefully. Allow the patient to tell the whole story then ask questions to fill in the gaps. Interrupt appropriately. Note non verbal clues. Correctly Interpret the information obtained. Show an interest. If the patient stops giving the story, it can be useful to provide a short summary of what has already been said and encourage the patient to continue. Avoid using medical terms.

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1. personal data:        

Name. Age. Nationality. Gender. Residency. Marital status. Children Occupation

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2. Chief complaint (CC):       

 

    

Time of admission (admitted when?): mention the date. Route of admission: through ER electively through OPC, or by referral. Complaining of (no medical terms &in a chronological order). If the CC is pain, mention the site. The duration (for how long?) of each symptom alone. Chronic illness (es), e.g., the patient is known to be….. since…. on (medications) ….., and mention if there are any complications. Analysis of the CC(s) in a chronological order: - Onset and offset. - Duration. - Course. - Character. - Severity. - Aggravating and relieving factors. - Associated symptoms. Systemic review of the systems involved in the CC(s). Previous episodes: if yes: - How many times? - When was the first and last episode? - Same or more severe episodes (progression). - How did it relieve? - Did the patient go to a doctor? - The diagnosis? - What was done (medications, investigation, or hospital admission)? Constitutional symptoms: fever, loss of appetite, and weight loss. Risk factors. hospital course: (what was done to the patient during this admission: investigations, medications, procedures and their results) Functional history: (how the disease affects the patient's life daily activity) e.g: going to the school or work. Analysis of the chronic illnesses that related to the CC(s): - It was diagnosed on (where and when?) by type of investigation? - Monitoring (yes or no, if yes how?). - Regular follow up in a health care center. - Medications. Always taken or missed. - Complications and their duration.

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3. Past History: 

   

Past Medical: - Chronic illnesses not related to the CC(s). - Childhood problems. - Any other disease, e.g infection, inflammation, tumor, and for each disease. a. When was diagnosed? By which type of investigations? b. Controlled or not. c. Drug compliance. d. Complications, and their duration. Past surgical or interventional procedures: What? Why? When? Complications? Hospital admissions: When? Why? What was done? ICU admission? Past accidents and their consequences, e.g. fractures, trauma. History of physiotherapy or rehabilitation.

4. Medication history: Drug

 

For (the disease)

route

dose

frequency

duration

Any complication (adverse effects) of the medications. Use of herbal medications (especially in liver diseases, or jaundice).

5. Blood transfusion: 

When Why? How many units? Complications?

6. Allergies:   

Against what, egg, food, drugs, contrast. What is the kind of the allergic reaction (symptoms)? How does it relief? - If negative, say: "No known allergy (NKA)"

7. Family history:     

Family members and their health. Causes of death. Similar illness (or presentation) in the family: duration, their ages when the disease presents. Any inherited disease: diabetes, hypertension, cancer, or any inherited disease that is illness related. Congenital abnormalities or diseases.

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8. Menstrual history:           

Age of menarche. Age of menopause. LMP (last menstrual period). Regularity (note if there is dysmenorrhea or amenorrhea). Duration. Amount. Pregnancies (number, any problem with pregnancy?). Deliveries (number, normal/c-section). Abortions (number, cause). OCP (oral contraceptive pills) and HRT (hormonal replacement therapy): if yes, for how long and which type. Any gynecological problems, e.g: bleeding, tumor.

9. Social history:           

Place of birth, and residency. Marital status and number of children. Who is taking care of the patient (to assess if he/she can do his/her daily activity or needs help). Level of education. Socioeconomic status. Occupation. Habits: smoking, drinking alcohol, drug abuse. Any activities or exercise. History of traveling to an endemic area (where?) or contact with infectious people (when?). History of close contact with animal. Immunization.

10.Systemic review: 

CVS, Respiratory, GIT, GUT, CNS, Endocrine, Rheumatological, Hematological, Skin.

11.Summary:      

Age. Gender. Chronic illnesses. CC(s) and the duration. Important negatives. The patient was admitted for further evaluation and management.

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 Examination: 1. Pre-exam Checklist : WIPE    

Wash your hands. Introduce yourself to the patient. Positioning of the patient and his/her Privacy. Exposure.

** Remember:  

Always examine from the right side of the patient (and tell the examiner if you are left handed). Ask the patient if there is any tenderness before touching him/her.

2. General appearance (ABCDE):      

Appearance: young, middle aged, or old, and looks generally ill or well. Body built: normal, thin, or obese. Connections: such as nasal cannula (mention the medications), nasogastric tube, oxygen mask, canals or nebulizer, Holter monitor, I.V. line or cannula (mention the medications). Color: jaundiced, pale, or cyanosed. Distress: in pain, respiratory (using accessory muscles), or neurological (abnormal movements) distress. Else: mental functions: consciousness, alertness, and orientation.

3. Vital signs: 

  

Pulse rate: - Rate: counting over 30 seconds, normally 60-100. - Rhythm: regular or irregular. - Synchronization by comparing with the other side (radioradial or radiofemoral delay). - Character and volume: determined from the carotid. Blood pressure (BP) : Normal BP defined as a systolic reading less than 140, and diastolic reading less than 90. Temperature: Normal body temperature ranges from 36.6-37.2 C. Respiratory rate: - It is traditional to count it while taking the pulse. - The normal rate at rest should not exceed 25 beat per minute (range 16-25).

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4. The hand: 

Dorsum: - Muscle wasting. - Pigmentations. - Skin lesion (including scars). - Tendon xanthomata*: hyperlipidemia.



Palm: - Signs of infective endocarditis such as Osler's nodes* and Janeway lesions* - Palmar xanthomata: hyperlipidemia. - Sings of a respiratory disease, or nicotine staining. - Palmar erythema (redness of the palms of the hands): liver cirrhosis, polycythemia, pregnancy. - Pigmentation of palmar creases: Addison's disease but may be normal in Asians and black. - Pallor of palmar creases: anemia (becomes clearer with hyperextend fingers). - Dupuytren's contracture*: alcoholism. - Raynaud's phenomenon*



Nail - Clubbing.* - Signs of infective endocarditis like splinter hemorrhage. - Leukonychia*: hypoalbuminemia, liver disease, or nephritic syndrome. - Koilonychias*: iron deficiency anemia.



Flapping tremor* - CO2 retention. - Hepatic encephalopathy. - Renal failure.

* See next page

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Dupuytren's contracture: A disease of the palmar fascia resulting in thickening and contraction of fibrous bands on the palmar surface.

-

Raynaud's phenomenon: abnormal response of fingers and toes to cold. First turn white (ischemia), then blue (cyanosis) and finally red (revascularization, it is the most severe and painful-stage ).

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Leukonychia: abnormal whiteness of the nails either total or in spots.

-

Koilonychias: dystrophy of the fingernails in which they are thinned and concave with raised edges.

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Flapping tremor: Involuntary jerking movements of the hands due to accumulation of toxins. The tremor is usually induced by extending the arm and dorsiflexing the wrist.

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Tendon xanthomata: nodules found in the tendons of the hands, feet, and Achilles.

A small, tender, nodular cutaneous lesion in the pads of fingers or toes.

Splinter hemorrhage: linear bleeding under a fingernail or toenail, resembling a splinter.

A small erythematous or hemorrhagic lesion, usually on the palms or soles.

Clubbing: A condition affecting the fingers and toes in which the extremities are broadened and the nails are shiny and abnormally curved.

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5. The head:  

Scalp: hair deficiency or excess. Eye: - Jaundice (in the sclera): liver disease, hemolytic anemia. - Pallor (in the conjunctiva): anemia. - Xanthelasma (patches of yellow skin around the lower or upper eyelids): hyperlipidemia, primary biliary cirrhosis. NOTE: Jaundice is better to be seen in the daylight.



Mouth: - Central cyanosis (blue discoloration seen in the tongue due to increase in the deoxygenated heamoglubin)



Oral hygiene. Dryness of the mouth: dehydration. Any lesion, e.g: ulcer, bleeding.

special smell: - Sweet smell "fetor hepaticus'': liver disease. - Ammoniacal fish breathe" uremic fetor": renal failure. - Cigarette smell in smokers.

6. The neck:    

Lymph nodes. Salivary glands. Thyroid. lf there is any swelling, describe it (site, size, shape, skin and surrounding tissue, consistency)

7. Lymph nodes: (see hematology examination) 

- Epitrochlear

- Axillary

- Cervical

- Supraclavicular - Inguinal

8. The lower limb:   

Any change in the nails, dorsal, or the sole of the foot. Peripheral pulses: popliteal, posterior tibial, and dorsalis pedis pulses. Lower limb edema.

9. The back: Sacral edema.

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 Important Analyses: 1. Pain:            

Onset. Duration. Site. Radiation. Character. Severity. Continuous or intermittent. Frequency, and the duration of each episode. Progressive or constant. Daily pattern. Precipitating, aggravating and relieving factors. Associated symptoms: symptoms of differential diagnosis.

2. Weight loss:   

Appetite: normal, decreased, or increased. How many kilograms? Over what time span has the weight been lost? What does the patient thinks the cause, e.g: thyrotoxicosis, malignancy... etc. More than 10% loss in 6 months is significant (make sure that the patient is not on diet).

3. Fever:        

Onset. Duration. Continues, remittent, or intermittently. Diurnal pattern. Changes in severity. Progression over time. Measured or not if yes: route and readings. Associated symptoms: - Chill: sensation of cold. - Rigors: uncontrolled shivering occurs when a patient's temperature rises rapidly.  Management: what was done to lower it?

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4. Diabetes and Hypertension: 

When was diagnosed? By which type of investigations? monitoring if yes, how? Regular follow up in a health care center. Medications, always taken or missed. Risk factor. Complications, and their duration.

   

Diabetes Presentation Polyuria, polydipsia, weight loss, lethargy. Risk factor

-

complication -

Family history. Obesity. Pancreatic disease, Endocrine disease: Cushing's, acromegaly. Drugs: corticosteroids, thiazide diuretics.

Vascular disease. Eye disease (ask about previous laser procedure). Neuropathy (ask about numbness). Nephropathy (ask about frothy urine).

Hypertension Visual impairment, nausea, vomiting, fits, headache, symptoms of acute cardiac failure. - Family history. - Obesity. - High alcohol intake and high salt intake. - Renal disease. - Endocrine disease: Cushing`s, acromegaly, Conn`s, pheochromocytoma. - Drugs: oral contraceptive, steroids, vasopressin. - Coarctation of the aorta - pre-eclampsia (3rd trimester of pregnancy). - Cerebrovascular disease (stroke). - Coronary artery disease. - Renal failure. - Peripheral vascular disease.

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5. Smoking:   

Cigarette, cigar or pipes. How many per day? How many years? Complications: - Cardiovascular disease. - Chronic lung disease, e.g: COPD. - Peptic ulcer. - Cancers. - Fetus damage or abnormality (if the patient is female).  If the patient stopped smoking, when and why?

6. Alcohol drinking:  

Which type? How much? How often? Complications: - GIT: erosion, bleeding, pancreatitis, liver disease, cancer. - CVS: arrhythmia, hypertension, cardiomyopathy. - CNS: blackout, peripheral neuropathy, cerebellar disease, dementia.

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History and Examination of the Cardiac System:  Major Symptoms: 1. 2. 3. 4. 5. 6. 7.

Chest pain. Dyspnea. Ankle swelling. Palpitation. Syncope. Intermittent claudication. Fatigue.

 Other items in the History.  Cardiovascular Examination: 1. Pericardium Examination. 2. Peripheral Examination.

Have Pride in Yourself..

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 Major Symptoms : 1. Chest pain or heaviness:  Duration.  Location.  Mode of onset: sudden or gradual.  Pattern: Constant or Progressive.  Radiation.  Character.  Course: continues or intermittent  Severity.  Precipitating, aggravating, and relieving factor.  Associated symptoms.

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2. Dyspnea (Cardiac dyspnea):  Exertional, the severity is assessed by New York Heart Association Classification (NYHA): Class I: only on heavy exertion. Class II: on moderate exertion (more than usual activity). Class III: on minimal exertion (at usual activity). Class IV: at rest.  Orthopnea: Dyspnea on lying down Severity reflected by the number of pillows been used.  Paroxysmal nocturnal dyspnea (PND): Severe dyspnea that wakes up the patient from sleep gasping for air.

3. Ankle swelling (edema):  Symmetrical.  Unilateral or bilateral.  The level: to the ankle, below the knee, the middle of the thigh, the abdomen, or the sacrum in bed ridding patients.  The progression: - From foot upward: heart failure. - Ascites then lower limb edema: constrictive pericarditis. - Worsens at evening, and improves during the night.

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4. Palpitation:  Unexpected awareness of the heartbeat.  The mode of onset and termination.  Specific triggers: exercise, alcohol, caffeine.  Frequency.  Duration of attacks.  Rhythm (ask patient to tap out): regular or irregular.  Fast or slow.  Syncopal attack or any associated symptoms.  Age of onset. 5. Syncope, presyncopal attack, and dizziness:  Syncope: transient loss of consciousness resulting from cerebral anoxia.  Presyncopal attack: transient sensation of weakness without loss of consciousness.  Dizziness: the world seems to be turning around  When and why?  Frequency.  Symptoms preceding the attack (i.e. an aura) : palpitation, chest pain, or dizziness).  The duration of the attack.  Any known diagnosis.  Associated symptoms. 6. Intermittent claudication: Pain in one or both calves, thighs or buttocks during walking more than a certain distance (the claudication distance).         

Description of the pain. Comes with walking, exercise, or at rest. The distant needed to cause pain. The time needed to recover. Reappearance after walking the same distant. Can the patient walk through the pain or not. How long have you had the problem? Progression: worsens or no change. Affecting lifestyle. What relieves the pain?

7. Fatigue:  Commonly with heart failure or diseases that lead to fatigue and cardiac symptoms like anemia, i.e. causes palpation and fatigue.

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 Other Items in the History: 1. Personal data: age and sex: - Male above 50: coronary artery disease (CAD). - Female above 30: rheumatic heart disease (RHD). 2. History of the presenting illness: Risk factors:  Ischemic heart disease (IHD): - Type II diabetes mellitus (DM). - Hypertension (HTN). - Hyperlipidemia. - Smoking. - Obesity and inactivity. - Family history. - Male sex and advanced age. - Raised homocysteine level ( is a naturally occurring amino acid found in blood plasma). - Type A personality.  -

Heart Failure: Risk factor of IHD. Congenital heart disease. Valvular heart disease. Thyrotoxicosis.

 -

Valvular heart diseases: Rheumatic fever. Congenital valvular disease. IHD. Heart failure. Connective tissue disease. Myocardial infarction (MI). Drug abuse (infective endocarditis).

 -

Arrhythmia: Risk factor of IHD. Excessive use of alcohol. Drug abuse. Stress. Certain over-the-counter (without a prescription )and prescribed medications. Dietary supplements and herbal remedies.

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3. Past history:  Past medical: - MI. - IHD. - RHD. - Resent dental work. - Transient ischemic attack (TIA). - Stroke: Loss of vision, Dysarthria, Monoplegia. - Thyroid disease.  Surgical (interventional) history:

- Open heart surgery or any cardiac or valvular surgery, e.g. CABG (coronary artery bypass grafting). 4. Family history:  Premature CHD in a first-degree relative: a male aged less than 55, or a female aged less than 65.  HTN, DM, or hyperlipidemia.  Familial hypercholesterolemia.  Systemic lupus erythematosus (SLE). 5. Social history:  Smoking.  Alcohol.  Caffeine consumption.  Drug abuse. 6. Medication history. 7. Blood transfusion. 8. Allergies. 9. Menstrual history. 10. Systemic review. 11. Summary.

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 Cardiovascular Examination: - Position: sitting. - Exposure: full exposure of the trunk (if you could not, tell the examiner from the beginning). 1. General appearance and vital signs:  Radial pulse: - Character*: anacrotic, plateau, bisferiens, collapsing, alternans. - Desynchronization: coarctation of the aorta ( a congenital narrowing of the arch of the aorta). - Water-hammer test: detects the collapsing pulse, which is pathognomonic for aortic regurgitation. (To detect this, the radial pulse of a supine patient with arm at side is firmly palpated with slight pressure until the pulse is obscured. The arm is then raised over the patient's head, with the arm perpendicular to the supine patient).



Blood pressure: Pulsus paradoxes: a change in the systolic pressure during inspiration more than 10mmHg.

2. Precordium examination: 

Inspection: a. Shape and deformities: - Pectusexcavatum (funnel shaped; depressed sternum: Marfan's syndrome*). - Pectuscarinatum (pigeon shaped; prominent sternum). b. Scars: median sternotomy. c. Devices: - Holter monitor: an ambulatory 24 hours ECG. - Pacemaker, or intracardiac defibrillator (lCD): usually below the left or right clavicle. d. Apex beat: with the aid of torch.

* See next page

21



Palpation:

a. Apex beat: The most inferolateral palpable pulse. - If it is impalpable, ask the patient to turn to the left. - The beat may be:  Normal.  Tapping: mitral stenosis (MS), tricuspid stenosis (TS).  Double impulse: hypertrophy cardiomyopathy.  Sustained: aortic stenosis, uncontrolled hypertension.

b. Parasternal heaves:

- Place the heel of your hand over the left of the sternum with the fingers lifted slightly off the chest, and ask the patient to stop breathing. - In the presence of a heave, the heel will lift off the chest wall with each systole. - Causes include:  Right ventricular hypertrophy.  Left atrial enlargement (not hypertrophy).

c. Thrill: - A palpable murmur (like the feeling on an arteriovenous fistula). - The site of a thrill is the same site of the valve, we detect its site by using the valve area, i.e. mitral area, tricuspid area..etc, or by using the anatomical position, i.e. 2nd intercostal space, 5th intercostal space... etc.

………………………………………………………………… * anacrotic: one in which the ascending limb of the tracing shows a transient drop in amplitude. *Plateau: one that is slowly rising and sustained. *Bisferiens:A double-beat pulse palpated over the carotid or brachial arteries, which is characteristic of obstructive cardiomyopathy and aortic regurgitation. *alternans: one with regular alternation of weak and strong beats without changes in cycle length. * Marfan's syndrome ; a disorder of connective tissue is caused by a defect in the gene controlling the production of fibrillin, and is characterized by abnormal elongation of the long bones and often by ocular defects, like partial dislocation of the lenses of the eyes, and heart defects.

22



Auscultation:

- S1 and S2. - S3 after S2 heard like a gallop rhythm: - Physiological in children, exercising people, and hyperdynamic circulation like thyrotoxicosis or pregnancy. - Heard in the apex area with mitral regurgitation (MR),AR, ventricular septal defect (VSD), or left heart failure. - May be detected in the left lower sternal edge with right heart failure or constrictive. - S4 after S3, and before S1 also heard like a gallop rhythm: - May be heard at the apex area in IHD, systemic HTN, MR, or AS. - Can be detected at the left lower sternal edge with pulmonary HTN or pulmonary stenosis (PS). - Murmur: a turbulent blood flow: - Occurs with valve stenosis or regurgitation. - It can be either systolic (comes with the pulse) or diastolic. - It may radiates to the axilla with MR, and to the carotids with AS. - The area of maximum intensity is the area at which the murmur is best heard. *Grades: 1. Very soft. 2. Soft. 3. Moderate without thrill. 4. Moderate with thrill. 5 Loud. 6. Very loud, heard even without stethoscope.

23

-

There are special maneuvers to increase the intensity of a murmur: a. Rightsided murmurs increase with inspiration, while left sided ones become clearer with expiration. b. Valsalva maneuver: expiration against closed epiglottis: helpful in mitral valve prolapse (MVP) and hypertrophic cardiomyopathy. c. Squatting 4-5 times: helps in MR and AS. d. Hand grip: ask the patient to squeeze a sponge 20 times, this will magnify the murmur of MR. >>Types of murmurs (see page 27-28).

 Techniques in auscultation: -

Start the auscultation in the mitral area using the bell to detect any low intensity murmur. Switch to the diaphragm and hear the whole area while you are feeling the pulse (to know which sound is S1). lf the sound is very low, call it (muffled) when you present your examination.

3. Peripheral examination:    -

Hand: Clubbing*: cyanotic congenital heart disease, infective endocarditis. Splinter hemorrhage*: vasculitis, infective endocarditis, antiphospholipid syndrome, and trauma. Cyanosis (acrocyanosis) in fingers and toes. Osler nodes*: infective endocarditis. Janeway lesions*: infective endocarditis. Tendon xanthomata*: occur in typeII hyperlipidemia. Face: Mitral facies is rosy, flushed cheeks and dilated capillaries: associated with long standing mitral stenosis. Eyes: Pallor, jaundice. Xanthelasmata (patches of yellow skin around the lower or upper eyelids): type II or III hyperlipidemia. Blue sclera: Marfan's syndrome. Arcus Senilis or corneal Arcus (Half or complete gray circle around the pupil).

* See page 10

24

 -

Mouth: Central cyanosis in the floor or sides of the tongue. Diseased teeth and petechiae are risks of infective endocarditis. High arched palate: Marfan's syndrome which is associated with AR or MR.



Neck: - Carotid pulse: better to get the volume and character. - Jugular venous pressure (JVP): >>see next figure  Stand on the right side of the patient, and focus on the site of the right jugular vein to detect its pulsation.  lf you could not see it, put the patient on 35˚ then on 25˚and then on 10˚ until you see it. If you did not, do the abdominojugular reflux test.  Abdominojugular reflux test: Put the patient on 45˚and press the abdomen while you are looking to his/her neck for 10 seconds. If the pulsation of the jugular vein is still rising and does not come back, the test is positive. - Kussmaul's sign: rise of JVP in inspiration.



The back: - Percussion and auscultation of the lung bases. - Sacral edema.



The abdomen: - Hepatomegaly. - Splenomegaly. - Ascites.



The lower limb: - Lower limb edema.

- Peripheral pulses.

25

How to differentiate clinically between high JVP and visible carotid pulsation? JVP Visible but not palpable 2 pulses per cycle Normally it decreases with inspiration If obliterated it fills from above downwards

Note

Carotid Pulse Palpable One pulse per cycle Not affected by respiration Filling from down upwards

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

Types of murmurs: a. Pansystolic, holosystolic murmurs (common): - From S1 to S2 in same intensity. - In MR, check for radiation, and if there is S3. - Also present in TR and VSD. b. Ejection systolic, mid systolic, crescendo-decrescendo murmurs (common): - From S1 to S2 but it stops before S2. - In AS, check for radiation. - Also present in PS, and hypertrophic cardiomyopathy c.

Late systolic (crescendo): - Starts actually before S2 - Presents in MVP.

d. Early diastolic (crescendo): - In AR, check for S3. - Also present in PR. - It is a muffled sound. e. Mid diastolic: - In MS, TS, and atrial myxoma.

- In severe aortic regurgitation, the early diastolic murmur willcontinued till themid diastolic. The murmur that is produced in such cases is called Austin Flint murmur. f. Continuous, mechanical, musical murmurs - Both systolic and diastolic: - Arteriovenous fistula. - Patent ductus arteriosus (PDA)* - Physiological in late pregnancy (mammary souffle).

…………………………………….. * A heart defect that occurs when the ductus arteriosus (the temporary fetal blood vessel that connects the aorta and the pulmonary artery) does not close at birth.

27

28

Summary

Note If your examiner ask you to examine the praecordium, start locally from the chest, then move peripherally if you have time.

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History and Examination of the Respiratory System:  Major Symptoms: 1. Cough. 2. Sputum. 3. Hemoptysis. 4. Dyspnea. 5. Wheezing. 6. Chest pain. 7. Fever. 8. Night sweats. 9. Hoarseness. 10. Hyperventilation.

 Other Items in the History.  Chronic Illnesses.  Respiratory Examination: 1. Local Examination: Front. 2. Local Examination: back. 3. Peripheral Examination.

Make Positive Statements...

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 Major Symptoms: 1. Cough:  Duration: - Acute: pneumonia. - Chronic: asthma, COPD.  Dry cough: ACE inhibitors, interstitial lung fibrosis, gastroesophageal reflux.  Productive cough: pneumonia, bronchiectasis.  Started as dry then became productive: complicated by pneumonia.  Awaking the patient from sleep: cardiac failure, esophageal regurgitation.  Changing in character: development of a new or serious underlying problem.  Diurnal variation.  Worsen at night: asthma, heart failure.  Immediately after eating or drinking: tracheoesophageal fistula, esophageal reflux.  Aggravating and reliving factors: dust, smoking... etc.

Causes of cough:

  

Acute

Chronic