History taking :

1) Personal history :

a- Name : …………………………………… b- Age :…………………………

c- Gender:.………………………………….. d- Relegion:…………………..

e- Marital status :………………………… f- Social class:……………….

g- Occupation : ……………………………… h- Residence :……………….

i- Special habits :……………………………. j- Handedness:………………….

2) Complaint : ( in patients own words + onset, duration & course )

……………………………………………………………………………………………………………………………………………………………………………………………………

3) History of present illness :

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4) Past history :

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

5) Family history:

6) History of drug intake: ( previous dis. & drug “dose, toxicity, duration”).

…………………………………………………………………………………………………

General Examination:

1) General condition :

a- Consciousness: b- Attention:

c- Memory: d- Mood:

e- Intelligence: f- Conception:( halluci.& illus.).

g- Perception ( Delusions ):

2) Body built :

a- Weight : ( normal, obesity or emaciation ).

b- Height: ( Normal , dwarfism or gigantism ).

c- Body configuration :

3) Decubitus: restless, lateral position, orthopnea, squatting & prayer.

4) Complexion : “ pallor, cyanosis & jaundice “.

5) Vital signs :

* Temp.: * B.P.:

* Pulse:

* Resp. rate:

6) Head examination:

* Cranium:

* Face : expression, color & asymmetry

* Eyes : brow, lid, ball, conj., sclera, cornea, pupil, lens & fundus

* Nose : size, saddle, discharge & working alae nasi

* Ear : tophi, discharge & low seated.

* Mouth : lips, odour, teeth, gum, tongue, buccal mucosa, palate, tonsils .

* Parotid gland :

7) Neck examination : abnormal position & movement , L.N., thyroid, & pulsations “ arterial & venous “.

8) Hand examination :

* Skin: temp., sweating, color, nodule

* Nails: clubbing, koilonychias, leuconychia, nail dystrophy, splinter hemorrhage.

* Musculoskeletal system of hand : wasting, involuntary movement ( tremor ), & deformities.

9) Lower limb:

* Edema : generalized or localized.

* Clubbing of toes.

* Peripheral arterial system.

* Venous system : ( DVT & varicose vein )

* Musculoskeletal system of foot: joints, muscles, deformities.

10) Breasts : in female & male.

11) L.N. : cervical , supraclavicular , axillary, , supra-trochlear,& inguinal.

12) Skin examination:

* Pigmentation & vitiligo.

* Dryness.

* Sweating.

* Elasticity :

* Thickness.

* Atrophy.

* Striae : ( alba, rubra & tensea ).

* Hair :hirsutism & fall of hair .

LOCAL EXAMINATION:

I ) Cardiac case :

1) Inspection & palpation :

a- Shape of the precordium & chest wall: bulge & deformities.

b- Apex beat : site, extent, character, rocking, double apex.

c- Other cardiac pulsations :

* To the left of sternum

* Pulmonary area : 2nd left interspace .

* Supra sternal notch & neck.

* Aortic area : A1( 2 nd rt interspace), A2 ( 3 rd left interspace ).

* To the right of sternum.

* Epigastric pulsation.

d) Thrill.

e) Palpable heart sounds : S1 , S2 & palpable gallop.

2) Percussion :

* Right border : normally, no dullness .

* Base of heart : 2 nd RT & LT interspace ( norm. resonant ).

* Left border : from axilla to apex ( Normally, no dullness outside the apex ).

* Bare area of the heart.

3) Auscultation :

** Areas of auscultation :

* Mitral area: lt 5 th intercostals space at MCL.

* Pulmonary : 2 nd lt space

* First aortic area ( A1 ): 2 nd rt space.

* second aortic area ( A2 ): left 3 rd space.

* Tricuspid area : lower end of sternum to the left.

**Comment on :

a) Heart sounds : S1, S2, S3 & S4.

b) Additional heart sounds : Gallop, Opening snap& ejection click.

c) Murmur :

i) timing: syst., diast. Or continuous .

ii) Site of max. intensity.

iii) Character.

iv) Intensity.

v) Propagation.

vi) Pitch.

vii) Position of patient.

viii) Relation to respiration.

ix) Effect of exercise.

d) Functional murmur :flow murmur & venous hum.

e) Pericardial rub.

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Diagnosis of cardiac case

* Aetiological diagnosis: eg :Congenital. Rh. , IHD.

* Anatomical diagnosis: Pericardial, endicardial, valvular.

* Physiological diagn. : Arrhythmia.

* Functional diagnosis : Compensated or decompensated.

* Complications : Infective endocarditis, chest infection.

II) Chest examination

1) Inspection :

a- Shape :barrel, flat, funnel, pigeon & kyphoscoliosis.

b- Symmetry :

* Retraction : fibrosis, collapse or pleural thickening.

* Bulge : i) one side : massive effusion & Pneumothorax.

ii) localized : chondroma, tumour, empyema necessitance.

c- Respiratory movement :

i) Rate : ( 14 – 18 /m. )

ii) Rhythm: hyperpnea & oligopnea, chyenstoke resp.

iii) Type of movement : abdomino-thoracic in male

iv) Pulse : Respiratory rate :( 4:1 ).

v) Chest movement : ( by deep inspiration ).

d- Accessory muscles :

i) Abnormal inspiratory movement ( eg. COPD ): contraction of neck muscles, intercostals retraction, supra clavicular indrawing.

ii) Abnormal expiratory movement: pursing of lips, - contraction of abd. Muscles & latissimus musc.

N.B. Litting’s sign :presence of lower intercostals retraction means absence of obesity, pleural effusion & diaphragmatic paralysis.

e- Apex beat & other pulsations:

f- Chest wall :( dilated veins, scars, sinuses & abscess ).

2) Palpation :

a- Chest expansion :

b- Trachea.

N.B. Trail’s sign: tendon of sternomastoid is more prominent to the side of the trachea is shifted.

c- apex beat + other pulsations.

d- Tactile vocal fremitus ( TVF ) :say 44 in arabic + palm of hand comparison of different parts of chest.( increased in consolidation , cavity with consolidation , collapse e’patent bronchus.

e- Tenderness.

f- Other palpable sounds ( rhonchi & pleural rub ).

3) Percussion:

* (along : parasternal line, MCL, midaxillary, scapular ),

N.B. Don’t forget percussion of traub’s area & tidal percussion.

4) Auscultation :

a- Breath sounds : ( intensity & character ).

b- Adventious sounds : ( rhonchi, crepitation & pleural rub )

c- Vocal resonance : ( as TVF but with stethoscope )

d- Special tests : i) succession splash

ii) Coin test

N.B.** Rhonchi may be :

i) Sibilant ( wheeze):high pitch + sides of chest.

ii) Sonorous: low pitch+ heard over midline.

** Crepitation :

i) Fine : heard near end of inspiration.

ii) Medium : - consonating ( metallic tone e’ consolidation )

- Non consonating: healthy alveoli e’ bronchitis.

iii) Coarse : heard during whole inspiration.

** length of expiratoy phase 1/3 of inspiratory phase.

III) G.I.T. examination

1) Inspection :

a- Abdominal contour: ( bulge or retraction ).

b- Abdominal movement.

c- Costal angle ( N. 90 ‘ ).

d- Divarication of recti.

e- Umbilicus ( site, shape & infiltration ).

f- Pubic hair distribution.

g- Hernial orifices.

h- Dilated veins.

i- Visible peristalsis.

j- Skin:( scars, sinus , fistula, striae & eruption ).

2) palpation :

a- Superficial palpation: (tenderness, rigidity , superficial swelling)

b- Deep palpation.

c- Dipping method : ( in massive ascites ).

d- Bimanual palpation : ( kidney & liver ).

N.B. Start exam. From Rt. Iliac fossa , then supra pubic, in an anti-clock direction for the 9 regions ( superficial then deep palpation ).

- Then, spleen, liver, kidneys & urinary bladder.

3) Percussion :

a- Ascites : i- shifting dullness ii- knee chest position iii- fluid thrill.

b- Liver : upper & lower border ( liver span ).

c- Spleen : ( + Heavy percussion of Traub’s area ).

d- Urinary bladder .

e- Gaseous distension .

f- Renal angle.

4) Auscultation :

a- Peristaltic sound.

b- Succussion splash.

c- Murmur.

d- Friction sounds.

e- Venous hum.

f- Fetal heart sounds & uterine soufflé

g- Puddle sign for ascites.

h- Scratch sign for liver enlargement.

N.B.:

** Causes of hepatosplenomegally :

i) Infection:( Bilharz., Malaria, Brucella, Milliary T.B., Infectious mononucleosis, Relapsing fevere ).

ii) Blood diseases : ( leukemia “ acute & chronic” , Myelosclerosis, Polycythemia rubra vera, Thalassemia , Plummer Vinson s., macroglobulinemia.

iii) Liver cirrhosis.

iv) Reticulosis : Hodgkin lymphoma & lymphosarcoma ).

** Cause of nodular liver :

i) Bilharziasis . ii) Malignancy.

iii)Hydatid disease