By Dr. Zahoor 1

 Look confident  Welcome the patient saying Asalam O Alaikum  Shake hand with patient  Introduce yourself – I am so and so medical student 2

 Explain that you wish to ask some questions to find out what happened  Make sure patient is comfortable and curtains are in place  Confirm patient’s name, age, occupation 3

 Ask principal symptoms and allow the patient to describe  Inquiry about the sequence of symptoms and events  Don’t ask leading questions in the beginning 4

 Chief complaint with duration  History or present illness  Past history e.g. past illness, admission, surgery  Drug history including allergies  Family history  Personal and social history – smoker/not, travel, animal contact 5

 With all symptoms obtain details like - Duration - One set – acute or gradual - Constant or periodic - Frequency - Precipitating or relieving factors - Associated symptoms 6

 Chest pain – 2 months Ask  Site of pain  Character – feeling pressure, dull, stabbing, shooting  Radiation 7

 Severity – interfere with work or sleep  H/O this pain before  Pain associated with nausea, sweating e.g. angina Note – When patient is unable to give history, then get necessary information from friends, relative 8

 History  Examination – General Examination – Systemic Examination  Problem list  Differential diagnosis and most likely diagnosis  Investigations  Diagnosis confirmed  Treatment 9

10

 General Examination includes - General appearance - Alertness, mood, general behavior - Hands and nails - Radial pulse and blood pressure - Lymph node – axillary, cervical - Face, eyes, tongue - Peripheral oedema 11

General appearance  Does the patient look ill ?  Alert, confused, drowsy  Co-operative, happy, sad  Obese, muscular, wasted  In pain or distressed 12

Hands and nails Hands  Unduly cold, warm, cold and sweaty (anxiety, sympathetic over activity)  Peripheral cyanosis  Nicotine staining  Raynaud’s  Palms – palmer Erythema may be normal, also occurs with chronic liver disease, pregnancy  Dupuytren’s contracture – thickened palmer skin to the flexor tendons of fingers (fourth finger) 13

Nails Clubbing  The tissue at the base of nail are thickened  The angle between the base of nail and adjacent skin of finger is lost  Nails become convex both transversely and longitudinally Causes - heart – infective endocarditis - lung – carcinoma bronchus, Bronchiectasis, fibrosing alveolitis - liver cirrhosis - Crohn’s disease 14

Nails (Cont)  Koilonychia – Concave nail (iron deficiency anemia)  Leukonychia – white nails (cirrhosis liver)  Splinter hemorrhages - Infective endocarditis  Pitting – psoriasis  Onycholysis – separation of nail from nail bed Psoriasis, Throtoxicosis 15

16 Finger clubbing

17 Koilonychia – spoon shaped nail from iron deficiency

18 Leuconychia

19 Splinter Hemorrhage in fingernails in bacterial endocarditis

20 Pitting of nails in Psoriasis

21 Dupuytren’s contracture- association Diabtes

Face, eyes, tongue  Mouth – look at the tongue moist or dry - Cyanosed (central)  Central cyanosis – blue tongue Cause: - Congenital heart disease e.g. fallot’s tetralogy - Lung disease e.g. obstructive airway disease  Peripheral cyanosis – blue fingers denotes inadequate peripheral circulation, tongue will be pink 22

Face, eyes, tongue (cont) Mouth  Look at the teeth – dental hygiene, caries  Look at the gums – bleeding, swollen  Smell patient’s breath - Ketosis – diabetes (sweet smelling breath) - Foetor – hepatic failure (musty smell) - Alcohol 23

Face, eyes, tongue (cont) Eyes  Look at the sclera – for jaundice (yellow sclera)  Look at lower lid conjunctiva – anemia (pale, mucous membrane of conjunctiva)  Eye lid – yellow deposit (Xanthelasma)  Puffy eyelid e.g. general oedema (Nephrotic syndrome), thyroid eye disease (myxoedema) 24

Eyes (cont)  Red eye – Iritis, conjunctivitis, episcleritis  White line around cornea, Arcus senilis – suggest hyperlipidaemia in younger patient, but has little significance in elderly  White band keratopathy – hypercalcaemia - Sarcoid - Parathyroid – hyperplasia - Lung oat – cell tumor - Vitamin D excess intake 25

26 Central Cyanosis of tongue

27 Peripheral Cyanosis hand and feet

28 Jaundice

29 Puffy eyes

30 Xanthelasmata

31 Arcus senilis

32 Kayser Fleischer rings (Copper deposition in Wilson’s disease)

33 Myopathic face

34 Severe pitting edema of the legs

35 Erythema nodosum (Sarcoidosis, Inflammatory Bowel Disease)

36 Pyoderma gangrenosum (Inflammatory Bowel Disease – Crohn’s and Ulcerative Colitis)

 Please remember to cover the patient and THANK him/ her at the end of examination. 37

38