Clinical ABCs

Batch 33 - UQU
1438 - 2017
Clinical ABCs
Main Editors
Hassan Sameer Tawakkul
Maryam Farraj Aloqalaa
Designed by
Sarah Khaled Alem
Bayan Muhammed Fatani
Project learders
Abdulmohsen Mohammed Alsofi
Elaf Faisal Obaid
2
The book was
reviewed by
Medicine
Dr. Amal Khotani
Dr. Sami Hammadi
Dr. Fahd Almalki
Dr. Ali Alkhatheri
Dr. Mohammed Saleh
Surgery
Dr. Solaiman Justaniah
Dr. Rani Alsairafi
Dr. Basem Alshareef
Dr. Mohammed Mirza
3
Contents
7
8
Clinical ABC 33’s team 9

INTRODUCTION
General HISTORY 11
General EXAMINATION 20
MEDICINE
- Cardiovascular system 23
Cardiovascular History
Chest pain 25
Palpitation 29
SOB 32
Syncope 36
Cardiovascular Examination
General + JVP 41
Pericardium + Murmur 49
- Respiratory system 59
Respiratory History
Cough 61
Hemoptysis 65
Fever 69
Respiratory Examination 72
RESPIRATORY SYSTEM EXAMINATION (Local Examination in front) 76
4
- Endocrine system 85
Endocrine History
Lethargy and Weight Gain 87
Weight Loss 91
Polyuria 94
-Central nervous system 99

Central nervous system History
Introduction 101
Headache & facial pain 103
Weaknesses 105
Seizures 107
Tremors 110
Central nervous system Physical examination 113
Higher centers examination 114
Cranial nerves examination 116
Upper limbs examination 128
Lower limbs examination 133
Surgery
Gastrointestinal system 139
Gastrointestinal History
Abdominal pain 141
Abdominal distention 149
Upper Gastrointestinal bleeding 152
Lower Gastrointestinal bleeding 155
Jaundice 158
Vomiting 161
Dysphasia 164
Diarrhea 167
Constipation 169
5
Gastrointestinal Examination 171
local abdominal examination 177
-Lump and Hernia 189
History of any lump 191
Types of hernia 194
Basic anatomy of hernia 195
Examination of hernia and lump 197
- Ulcers and Diabetic Foot 201

History and Examination of Ulcers 203
Peripheral pulses Examination 207
- Neck Masses and Thyroid Gland 211

History of neck mass and thyroid lumps 213
Examination of neck mass 216
Examination of thyroid gland 220
Examination of lymph nods 227
- The Breast 229

Breast History
Breast lump 231
Breast pain 235
Nipple discharge 239
Breast Examination 243
- Sinus and Fistula 245

Sinus and fistula definitions 247
Hiatory of sinus and fistula 247
Examination of sinus and fistula 250
- Urology 253
Urology History
Hematuria 255
Dysuria 259
6
Urinary incontinence 262
‫رصان ‪.‬د ةملك‬
‫‪7‬‬
‫يناه ‪.‬د ةملك‬
‫‪8‬‬
Clinical ABC 33’s team
Course directors : Abduleilah Hasan Alloheiby
Abdulmohsen Mohammed Alsofi Israa Abed AlFadhli
Elaf Faisal Obaid
Demonstration committee :
Scientific committee : leaders:
Leaders: Enas Mohammad ali munshi
Asya Rezayq Alsulami Abdullah bakur bannani
Hassan sameer tawakkul Members:
Membres: Rawan Osama Mirza
Maryam Farraj Aloqalaa Waad Abdulaziz Haroun
Wejdan Jumyaan Alharbi Raniya Abdulrahim Alsiyami
Abdullah bakr bannani wejdan qublan almuqati
Angham Marzouk Ghazna Batool Farhoun Qari
Alaa Mohammed Khayat Rawabi Daafi Majrashi
Hamzah Ahmed Alkharouby amjad ahmad bugis
afnan abdullah basallom Tharaa Waleed Rambo
Raghad Musallam Alhejaili Ruqayyah Sami Kamal
Nada Abdulrahman Telmesani Asya Rezayq Alsulami
Abdullah suliman yamani Ebtehal Hussain Al_Thobaiti
Ali Hasan Alkhzaim Asma salem almatrafi
Abdulrahman Osama Mansour Khawlah Khaled Nafadi
Rowaynah Waild Aziz Alrahaman Ohood abdullah almonief
Salman Gherman Alamri Shahad abdullah almagboul
Sahal Mohammed Alsuwayhiri Maumounah Faisal Al-Najjar
Abdulrahman Ali Shata Maryam Farraj Aloqalaa
Shifaa Mansour Alsharif Abrar Ghazi Najjar
Abdullaziz Samir Hazzazi Majd Mamdouh Mryani
Reem Mohamed AlGhamdi Hajar Aown Allah Alsulami
Al-Hanoof Jamal Al-Bokhari leena abdulrhaman Alharthi
Haneen Mohammad Banjar Basmah ali alrowathi
Ghada Fareed Qutub Bushra Abed AL-harbi
Tharaa Waleed Rambo Rawan Mohammad Natto
Zahra’a Abdullah Assmary Wedyan Hassan Al-mosa
Abdulaziz Abdullah Joharji Shatha Awwadh Althobaiti
Salma Zaki Jastaniah Shahad fuad binafeef
Khawlah Khaled Nafadi Asma’a fayez basakran
Nizar Adnan Almaghrabi Amar Nayf Akbar
Rawabi Ahmed Barnawi Mohammed maysha almuqati
Ibtihal tariq yamani Abdullah suliman yamani
Abrar Ghazi Najjar Nibras Khaled Al Jabri
Razan Rashad Baghdadi Abdullah ahmed almontashiri
Aminah Hussain AlAli Majd masoud ahmad
Shaher Odah Aldadi Sulaiman Mohammed Hushlul
Wajd Ramzi Felemban Ali Hasan Alkhzaim
Mohammed Salem Alqithami Abdulrahman Osama Mansour
Hootaf Saeed Bafhaid Rayan Ali Alghamdi
Ohood Ayed Allogmani Faisal Mohammed Dhahi
Salwa obed alomeri Saleh Maneea Alloqmani
Bassam Adel ALJabri Osama Abdulrahman Alharthi
Shahad Hani Almuntaser Abdulrahman Ali Shata 9
Suhaila Kamal Qari Abdulaziz Abdullah Joharji
Bushra Abed AL-harbi Albara Ibraheem Faqihi
Sara Ahmed Al-Edreesi Ziyad Ali Alnefaie
Anmar Mohammed Batawi Aamer Ali Alzahrani
Yasir Abdulhai Siddiq
Abdulqader Taha Almuallim Ahmad Majed AlGhamdi
Muhannad Mohammed Bahashwan Abdullah Ahmed Almontashiri
Rayan Ali Barakat Marwan osamah khayat
Abdulmohsen Mohammed Alsofi Hussam Khamis Alzahrani
Siddiq Mazin AlMaghrabi Abdullah bakur bannani
Mohammed Essam khayat majd masoud ahmad
Abdulrahman Yahya Maashi
Mohammed Ahmed Ashary Registration, Design, Gifts Committee:
Rayan mohammed alghamdi Leaders :
Sadagah Marwan Wazzan Ghadi Mohammed Alotaibi
Abrar Abdullah Khan
Media committee : Dania Ramzi Jei
Leaders: Abdulrhman Mohsen Althaqafi
Bayan Muhammed Fatani Members :
Abdulqader Taha Almuallim Yara Mohammad bojan
Members : Leenah Bishr Al-Kareem Elyas
Lamis hisham bosi Majd Mamdouh Mryani
Abeer Ali Alshareef Abrar Abdullah Khan
Haneen Mohammad Banjar Rawan Mohammad Natto
Sarah Khaled Alem Taghreed Ahmed khan
Bashayer Abdulrahman Althaqafi Bashair waleed melibari
Abrar Abdullah Khan Bayan Nasser Bugis
Fay Faisal M.Nwawi Raneen mohammad masarit
Suhaila Kamal Qari Mayar Khalid Shaffei
Ruqayyah sami Kamal
Exam committee : Amar Nayf Akbar
Leaders : Manar Matar Al-Slymi
Khawlah Khaled Nafadi Bayan Bishr al-Kareem Elyas
Members : Muruj Salah Filfilan
Ghada Fareed Qutub Abdulhamed ahmed sulaimani
Mazad Ali Allehyani Khalid A. alsalmi
Sarah Khaled Alem Mohammed Salem Alqethami
Raneen mohammad masarit
Rawabi Ahmed Barnawi Design Committee:
Ebtehal Hussain Al_Thobaiti Leader :
Batool Farhoun Qari Abdullah Mohammed Binjabi
Elaf Mohammed Taha Fakeih Members :
Ohood Ayed Allogmani Osama Abdulrahman Alharthi
Shatha Awwadh Althobaiti Abdulaziz Mohammed Bakhsh
Shuruq Abdullah Alamri Abdulaziz Abdullah Joharji
Ruqayyah sami Kamal Nasir Ahmad Alsubai
Ghadi Mohammed Alotaibi Anmar Mohammed Batawi
Asya Rezayq Alsulami
Bayan Nasser Bugis
Amar Nayf Akbar
Elaf Faisal Obaid
Rawan Osama Mirza
Haneen Mohammad Banjar
Hammam Abdullah Alfadhli
Anmar Mohammed Batawi
Faisal Mohammed Dhahi
Rayan Ali Alghamdi
10 Yahya Salim Alzahrany
Sadagah Marwan Wazzan
Abdulqader Taha Almuallim
Tayy Nasser Al Juhani
Nibras Khaled Al Jabri
Rayan Ali Barakat
General Chapter
Shahad hani Almontaser
Zahraa Abdulla Assumairi
Revised by:
Razan Rashad Bughdadi
12
GENERAL HISTORY
YOU SHOULD KEEP IN MIND:

-It is very important to establish a good doctor-patient relationship. Al-
ways deal with the patient in a polite manner. This will make the patient
more comfortable and leads to better communication and better history.
-Before taking the history: Introduce yourself, check to make sure that
privacy of the patient is maintained, and take permission from the pa-
tient to ask him/her a few questions.
-Listen carefully, and allow the patient to tell the whole story, and then
ask questions to fill in the gaps in your history.
- Note the “non-verbal clues”: how the patient talks, walks and his/her
expressions.
- Avoid using medical terms, and always try to use simple clear words.
General Considerations:
• Taking the medical history is the first step in making a diagnosis.
• History taking involves more than listening, you must observe actively.
• The skill of a good history taking is the quality of a good doctor.
• It is not a hard skill, all what you need is to put an extra
effort and PRACTICE more! You will be a Star.
• A History form is a helpful tool to help you practice in the
Hospital, it will help you to be thorough and organized.
• Make sure you practice with and without the form in order to
master this skill by the end of the course.
• Remember the more you practice, the more you improve your
skill.
•you will be surprised How fast your progress is if you put
enough time & effort.
13
These are the 13 components of history
we mostly use
1. Personal data Chief Complain: is the
patient’s reason to seek
2. Chief complain and duration medical help, don’t use
any medical terms or spe-
3. History of presenting Illness (HPI)
cific diagnosis, just men-
4. Associated symptoms tion the patient’s complain
in his own words.
5. Risk factors
6. Constitutional symptoms
7. Systemic review
8. Past medical history
9. Past surgical history
10. Drug and allergy
11. Family history
12. Social history
14
General History Form
1-Personal Data:
Name: For identification and to be familiar with the patient.
Age: Certain diseases are related to certain age groups.
Gender: Some diseases are more common in males / females.
Nationality: Certain diseases are related to certain nationalities.
Home and residence: Certain diseases are related to certain areas.
Occupation: Some diseases are related to certain occupations.
Marital status.
Route and date of admission: through OPD or ER.
2-Chief complain & duration:

•Main complaint:
- What brought you to the hospital?
- Usually there’s one but there could be more than one chief complain.
e.g. Single complain: only present with chest pain.
More than one: fever with convulsion.
- Use patient’s own words, if the patient said he has shortness of breath
write it as it is, don’t write dyspnea because it’s a medical term.
• Duration of the symptoms by minutes/hours/days/months/years.
- To know if it’s acute or chronic.
3-History of presenting illness (HPI):

• The analysis of chief complain “no matter how many” analyze each
complain alone by repeating questions according to the complaint.
• Remember that every chief complain has its own questions, it’s not
necessarily to ask them all in one chief complain.
Here we just give you an example, so you get familiar with them.
We use this set of questions mostly with pain.
• Don’t worry about memorizing all of them now, they will be discussed later
separately in the book in each chief complain.
To make it easier just remember this mnemonic (SOCRATES + TP):

Site
- Where (ask the patient to point by his finger to the site of
maximum intensity).
- Localized or diffused.
Onset
- Sudden or gradual.
Character
- If it is pain ask if it is (sharp - burning - crushing - dull - stab - burn
-cramp).
15
General History Form .. cont.
Radiation:
- Comes with pain, it is different from shifting pain.
- In radiation the pain is in the abdomen and at the same time it’s ra-
diating to the back as in pancreatitis.
- But in Shifting pain, the pain starts around the umbilicus then it is
shifted to the right iliac fossa and the patient does not feel it any
more around the umbilicus as in appendicitis.
Alleviating (relieving) factors
- Anything makes the symptom better, as using analgesic medication
or leaning forward in pericarditis.
Timing
- When did the patient feel well last time?
- Continuous or intermittent (if intermittent ask about the frequency,
number of episodes per day, last for how long and the time between
two episodes).
Exacerbating (aggravating) factors:
- Anything makes the symptom worse, as moving around if the patient
has pericarditis, eating in duodenal ulcer.
Severity
- Best way in assessment of severity is to ask whether it’s interfering
with the patient’s daily activity and sleeping or not
- Or by using 0-10 scale.
Time course: If it’s chronic, why it came now and if it’s worse at morn-
ing or at night.
Progression: Getting worse, better or staying the same .
For fluid:
DOQ AAAAC
(Duration, Onset, Quality*, Aggravating, Alleviating, Associated symptoms, At-
tribution, Complication)
*For Quality: CCP ABC2O

(Character, Course, Frequency, Progression, Amount, Blood, mucus, Color +
Content, Odor)
4-Associated symptoms:
It is a systemic review of the related systems. For example, if the patient has
chest pain, the related systems are cardiovascular and respiratory system. If
he has burning during micturition, so it is genitourinary system. And if he has
Abdominal pain, so it is Gastrointestinal system.
So here you will ask about each and every possible symptom of the
related system (look at the table of the systemic review and use it
according to the system you need).
16
5-Risk factors:
Related to the differential diagnosis of the chief complain.
For example:
If the patient comes with hemoptysis, he may have lung cancer so
smoking is an important risk factor, you ask about it in this part, you don’t wait
until you get to the social history. This is also important when you present your
history. As the listener will understand the case very quickly.
6-Constitutional Symptoms:
• Fever, fatigue, loss of appetite, loss of weight and night sweating.
• If it’s present it is highly indicative of malignancy or TB.
7-Systemic Review:
• Here you will ask quickly about all other body systems, as the patient may
forget to tell you about other complains and sometimes it could be very serious
if you
miss this part.
• You can approach this by asking about systems from head to toe:
1- CNS
Headache, facial pain, neck pain, swallowing disturbance, limb weakness, in-
voluntary movement, loss of consciousness, dizziness, vertigo, fits or convul-
sion, gait disturbance, disturbance of sphincter control, vision/hearing/swell-
ing/smell /speech abnormalities, tremor, numbness and sensory loss.
2-Cardiovascular system
Chest pain, orthopnea, PND, palpitation, dyspnea, cyanosis, cold extremities,
ankle swelling, syncope, intermittent claudication and easy fatigability.
3-Respiratory system
Hoarseness of voice, wheeze, dyspnea, cough, sputum, hemoptysis, sore throat,
chest pain, fever and night sweat.
4-GIT
Nausea, vomiting, hematemesis, dysphagia, odynophagia, regurgitation,
heart burn, abdominal pain and distension, change in bowel habit, pale
stool, dark urine, pruritus, jaundice, melena, hematochezia, weight
change, loss of appetite and fever.
5-Genitourinary
Genitourinary pain, discomfort, frequency urgency, incontinence, interrupted
stream, blood in urine, hesitancy, weak stream, post-void dribbling, changes in
quantity & color, incomplete emptying and retention.
17
6-Musculoskeletal : joint swelling and joint pain.
7-Hematology
Jaundice, bone pain, symptoms of anemia (dyspnea, fatigue, headache,
faintness, palpitation), spontaneous bruising, skin rash and prolonged bleed-
ing.
8-Skin
swelling (lymph node), bruising, itching, color changes and rashes.
8-Past medical history (PMH):

• Any previous history of the same attack?
• Chronic disease (DM- HTN- IHD- TB- IBS- IBD- Liver or Renal diseases).
• Previous hospital admission (why, duration, investigation, treatment).
9-Past surgical history (PSH) :

• Previous operations (type, when, complications, outcome).
• Blood transfusion.
10-Drug and allergy history:

•If the patient is taking any medication ask about:
- the name, doses, how many times/day, duration, side effect.
- Ask about antibiotic specifically, you will be surprised that
some patients don’t consider it as a medication!
• Allergy:
- Allergy to drugs, food, dust and animals.
- What happens during the attack of allergy (itching -discoloration - SOB -
cough).
- History of immunization, the usual ones like tetanus every 10
years or recent one like HPV or influenza.
11-Family history:
• Family history of similar illness.
• Chronic diseases (HTN - DM - asthma -IHD - CVA MI - hyperlipidemia - blood
diseases).
• Genetic disease.
• Cancer.
12-Social history:
• Marital status and number of children.
• Occupation.
• Educational level.
• Alcohol and drug abuse.
• Smoking: either passive or active (type, duration: number of packs per
day) or X smoker (how many years?).
18 • Travel: (where, food and water ingestion, how did he live there, immuni-
zation).
• Pets.
• Diet and physical activity.
• Sexual contacts.
Summary of history
• After you take history as above, you will write it down.
• You will be asked frequently to give a summary after you
finish.
• Summery contains (Age, gender, admission, chief complain and
duration, known illness, important positive, important negatives,
brief drug history and most important risk factor).
After finishing your history, it is crucial that you examine the patient to
confirm your diagnosis or rule out certain differential diagnoses. Each sys-
tem has a different examination that you will do based on the patient’s
complaints. In this chapter, we will discuss the general examination you
should do for all patients regardless of the system.
19
Before starting your examination:
- Be sure that you are dressed appropriately and have all the necessary
tools.
- Make sure that you are in a well-lighted room.
- If you are (a male doctor) examining a female patient ensure the pres-
ence of a chaperone.
- Stand on the right side of the patient.
General Examination
WIPPPER:
Wash your hand.
Introduce yourself.
Ask for Permission.
Check Privacy of the patient.
o Close the door or curtains of bed.
Position.
o According to the system you would like to examine
Exposure.
o According to the system you would like to examine
o Expose when you reach the site of examination.
o Never examine alone the opposite gender.
Stand on the Right side of the patient.
System Position Exposure

The whole chest to
CVS 45 degree
the umbilicus.
From chest to waist.
(cover the breast
45 degrees and/or sitting
Respirato¬ry when not needed if
over the edge of the bed.
the patient is a fe-
male)
From the nipple to
Flat on the bed with the thigh. (cover the
GIT
1 pillow. groin when not need-
ed)
Sitting over the edge of the
CNS Expose related limbs.
bed.
20
General Examination .. cont.
ABCDEV:
A = Appearance
- Patient looks ill or well.
- Conscious and alert or comatose.
- He is lying comfortably on bed or not.
- To assess patient orientation ask about place, time and per-
son:
. time (for example: the time of day, day of week, duration of hos-
pitalization …etc.).
. place (for example: the name of hospital, city…etc.).
. person (for example: the name of relative or the name of doc-
tor).
B = Body built
- If average body weight, underweight, overweight, obese or cachectic.
- mention that you have to confirm it by the body mass index (BMI).
C = Color
- Color: normal, pallor, jaundiced or cyanosed.
Mention that you have to confirm it later by looking into the sclera for
jaundice, the conjunctiva for pallor, fingers and tongue for cyanosis.
D= Distress and deformity

- Signs of respiratory distress include usage of the accessory muscles,
shrugging of the shoulders, tachypnea (RR more than 25 bpm) and nasal
flaring.
- Deformity as scoliosis, kyphosis... etc.
E=Environment:
- Connection to cardiac monitor, IV line, cannula, urinary catheter, drain
or oxygen mask
- If there is sputum container or wheelchair next to the patient.
V=Vital Signs:
- Heart rate (HR), respiratory rate (RR), blood pressure (BP), tempera-
ture and O2 saturation.
21
Vital sign Normal Abnormal Comments
*Check the radial pulse at lateral side of the wrist.
*Use tips of index and middle fingers to palpate it.
*You should comment on:
- Rate: for 30 seconds ×2 or:
Tachycardia
60-100 beats 15 seconds × 4 (if regular).
>100 Brady-
Pulse per minute - Rhythm: regular or irregular.
cardia
(bpm). - Volume: large, average, low.
< 60
- Character: collapsing pulse, pulsus paradoxus,
pulsus alternans, …
- Radio-radial, radio-brachial & radio-femoral
delay.
Measure the blood pressure with the sphygmoma-
nometer:
1. Ensure the cuff is in proper size of the patient.
(If it’s too small or too big it will give wrong read-
ing).
Optimally
2. Wrap the cuff around the upper arm and the
< 120/80
bladder centered over the brachial artery (at
the antecubital fossa) and put the diaphragm of
Normal HTN:
stethoscope on it.
Blood pres- 120-129 / 80- >140 Systolic
3. Palpate the radial artery and start to inflate the
sure 84 or
cuff, stop inflating when the radial pulse disap-
>90 Diastolic
pears. (To avoid auscultatory gap).
High normal
4. Start to deflate slowly, the first sound to be
130-139 / 85-
heard is (KI) which indicates systolic blood pres-
90
sure, the last sound is (KV) indicates the level of
diastolic blood pressure.
5. The blood pressure normally vary between the
arms up to 10 mmHg, in the legs up to 20 mmHg
higher than arms.
*The patient should not be aware that you are
counting his respiratory rate because he may got
nervous and that will lead to increase his rate,
12-20 breath Ta c h y p n o e a
Respiratory remember it’s the only sign under the voluntary
per minute >20 Bradyp-
rate control.
(bpm) noea <8
*Stand in front of the patient, watch his chest rise,
each rise is considered as 1 in respiratory rate,
calculate it over one minute.
Measure the temperature by thermometer.
Remember that temperature differs from site to
site in your body.
Te m p e r a - 36.8o – 37.2o Fever > 37.3o Organ Normal Fever
ture ( Oral ) ( Oral) Mouth 36.8 C > 37.3 C
Axilla and ear 36.4 C > 36.9 C
Rectum 37.3 C > 37.7 C
O2 satura-
100 % - 95 % < 95 %
tion
After that, you can go to specific examination starting from hand, arm, fore-
arm, face, mouth, neck, chest, abdomen, back and lower limbs.
22
Cardiovascular System Chapter
Rawan Osama Mirza
Ebtihal Tariq Yamani
Salwa Obed AlOmairi
Bassam Adel Aljabri
Revised by:
Abdullah Bakur Bannani
24
1. History of chest pain
Introduce yourself, take permission from the patient to take history
1-Personal Data
Name ,Age ,Gender, Nationality, Route of Admission (Through OPD or ER)
2-Chief Complaint (CC)

Chest pain ,ask about the duration of symptoms (minutes /days /moths /
years)
3- History of Presenting Illness(HPI)

Site
Where do you feel the pain? If diffused, where do you feel the pain is
worse?
Onset
How did the pain start (sudden or gradual )?
Character
Can you describe the nature of pain?
Radiation
Is the pain radiating or shifting anywhere else?
Exacerbating and alleviating factors
Is there any alleviating or exacerbating factor? ( walking , running ,
medication )
Time course
Is it intermittent?
If intermittent:
-How many times did you feel this pain?
- How long did the pain persist in each attack?
Severity
Can you determine the severity of pain in scale out of 10?
Is it affecting your daily activity ? doesn’t make you sleep at night ?
waking you up from sleep ?
Progression
Is getting worse or does it stay the same?
4- Associated Symptoms
-CVS associated symptoms :(Chest pain, Dyspnea, Orthopnea, PND, Palpita-
tions, Syncope, Ankle swelling, Easy fatigue, Intermittent claudication, Cold
extremities , Cyanosis)
-Respiratory associated symptoms:( Wheeze , Cough , Sputum , Hemoptysis ,
Chest pain , Dyspnea , Hoarseness of voice, Sore throat )
- GI associated symptoms:( Vomiting , Nausea , Heart burn , Abdominal pain
,Change bowel habit)
25
1. History of chest pain .. cont.
5- Risk Factor
- Have you had angina or a heart attack in the past?
- Have you had hypercholesterolemia? Did you treat it?
- Has anyone in the family had angina or heart attack? Who?
- Have you had kidney problems?
6- Constitutional Symptoms
1.Fever
2.Fatigue
3.Weight loss
4.Loss of appetite
5.Night sweating
7- Systemic Review
- DO you have :( Headache , Neck pain ,Visual disturbance , Seizures , Limb
weakness ) (CNS)
- DO you have :( Dysuria , Hematuria , incontinence , polyuria ) (GU)
- DO you have :( Joint pain , Bone pain , Anemia ) ( Hematology + Rheuma-
tology )
- DO you have :( Bruising, Itchiness ,Color changes, Rashes, Swelling) ( Skin)
8- Past Medical History (PMH) :

- Any previous history of similar attack?
- Any Chronic disease ( DM- HTN- Ischemic Heart Disease - Asthma – TB-liver-
Renal-Irritable Bowel Syndrome ) disease ?
- Previous hospitalization (why, when )?
9- Past Surgical History :

- Any Previous operations? (type, when, complication, outcome)
- Any Blood transfusion.?
10-Drug and Allergy:

- Any drug the patient is using?
If using ask about: ( Name, doses, how many times/day, duration, side ef-
fect.)
- Allergy to drugs or type of food or dust ?
11- Family History

- Family history of similar symptoms
- Chronic diseases in the family (HTN - DM - asthma -IHD - hyperlipidemia -
blood diseases)
- Genetic diseases
- Cancer
26
12-social History :
- Marital status , if there any children
- Occupation
- Educational level
- Smoking : either passive or active ( ask about type , duration,
no of packs per day then calculate it in pack - year ) or
Ex – smoker ( for how long?)
- Alcohol &Drug Abuse Best initial test
- Travelling & Immunization for all forms
of chest pain is
-Sexual contact ECG
- Diet and Physical activity
reference step up p 2
13- Differential Diagnosis : (reference talley P46-47)
Myocardial infarction(MI)
1. Central , heavy pain
2. Onset at rest
3. Duration of pain in MI is 30 min
4. Radiate to the jaw or left arm
5. Sweating
6.Not relief with nitrates
Cardiac 7. Associated with ( nausea and vomiting)
Angina
1. Central , heavy pain
2. Onset with exertion
3. Duration of pain in angina is 5 – 10 min
4. Radiate to the jaw or left arm
5. No sweating
6. Rapid relief with nitrates
Aortic dissection
1. Tearing pain
Vascular
2. Very sudden onset
3- Radiates to the back
Pericarditis or pleurisy
1. Sharp or stabbing pain
2. Worse with respiration
Respiratory 3. Unaffected by nitrates
4. Present at rest
5. Not exertional
6. Worse supine ( pericarditis )
1.history of chest trauma
2.get worse with position changing
Musculoskeletal
3.chest wall tender
4. Localized pain
Gastro- oesophageal reflux (GERD)
1.Burning pain
GIT 2.Onset may be when supine
3.Present at rest
4. Unaffected by respiration
27
Most common
Functional Classification in established heart cause of death in
disease : first few days after
MI episode is Ven-
Class Patient Symptoms triculr arrhythmia
No limitation of physical activity. Ordinary
I physical activity does not cause fatigue, reference step up p 12
palpitation, dyspnea (shortness of breath).
Comfortable at rest. Ordinary physical
II activity results in fatigue, palpitation,
dyspnea (shortness of breath). The management in pa-
tient with MI (MONA)
Comfortable at rest. Less than ordinary 1-Morphine 2-Oxygen
III activity causes fatigue, palpitation, or dys- 3-Nitroglycerin
pnea. 4-Aspirin 5- B- blocker
IV Angina or dyspnea at rest 6- ACE inhibitor
7- IV-Heparin
Clinical classification of angina from European society of Cardiology :

( Reference : talley p 48 )
Meets all three characteristics
1-Retrosternal chest discomfort
Typical angina
2- Provoked by exertion or emotion
3- Relieved by rest or GTN (glyceryltrinitrate) or both
Atypical angina Meets two of the above characteristics
Non cardiac chest pain Meets one or none of the above characteristics.
28
2. History of Palpitations
Introduce yourself, take permission form the patient to take history
1-Personal Data
2-Chief Complaint (CC)

Palpitations, Ask about the duration of symptoms
(minutes /days /months / years)
3- History of Presenting Illness(HPI)

Onset
-How did it start and end (mode of onset and termination)?
- Did the episodes start and stop very suddenly? (Supra Ventricular
Tachycardia = SVT )
• Is there an abnormal beat felt other than the normal heart beat?
• Does the heart seems fast or slow? Have you counted how fast? Is it
faster than it ever goes at any other time, e.g. with exercise?
• Does the heart seems regular or irregular?
If it is irregular:
-Is it like a normal heartbeats interrupted by missed or strong beats &
worse at rest? (Ectopic beats)
-Or completely irregular? (Atrial fibrillation = AF (
•How long did the episodes last?
•Exacerbating and alleviating factors
-Is there any aggravating factors? Especially (exercise, alcohol, Caf-
feine).
•Can you terminate the episodes by deep breathing or holding your
breath? (SVT)
•Is there a sensation of pounding in the neck? (SVT)
•Have you had an attack before? Did you ever recorded an episode on
an ECG?
•Have you lost consciousness during an episode? (Ventricular
Arrhythmias or high grades AV block)
•Is there heart trouble of this sort in the family? (Sudden death
Syndrome)
•Have you had other heart problems such as heart failure or a heart
attack in the past?(Ventricular arrhythmias)
4- Associated Symptoms
-CVS associated symptoms :(Chest pain , Dyspnea , Orthopnea, PND , Palpita-
tions , Syncope , Ankle swelling , Easy fatigue , Intermittent claudication , Cold
extremities , Cyanosis)
29
2. History of Palpitations .. cont.
5-Risk Factor
- Have you had an angina or a heart attack in the past?
- Have you had hypercholesterolemia? Did you treat it?
- Has anyone in the family had angina or heart attack? Who? How old
were they?
- Have you had kidney problems?
6- Constitutional Symptoms :
1.Fever
2.Fatigue
3.Weight loss
4.Loss of appetite
5.Night sweating
7- Systemic Review :
- DO you have:( Wheeze , Cough , Sputum , Hemoptysis , Sore throat )
(Resp)
- DO you have :( Vomiting , Nausea , Heart burn , Abdominal pain ,Change
bowel habit ) (GIT)
- DO you have :( Headache , Neck pain ,Visual disturbance , Seizures , Limb
weakness ) (CNS)
- DO you have :( Dysuria , Hematuria , incontinence , polyuria ) (GU)
- DO you have :( Joint pain , Bone pain , Anemia ) ( Hematology + Rheuma-
tology )
- DO you have :( Bruising, Itchiness ,Color changes, Rashes, Swelling) ( Skin)
- Any previous history of similar attack?
- Any Chronic disease (DM- HTN- IHD- Asthma – TB-liver- Renal- IBS ) disease ?
- Previous hospitalization (why, when )?

- Any Previous operations? (type, when, complication, outcome)
- Any Blood transfusion.?
10-Drug and Allergy :

- Any drug the patient is using?
If using ask about: ( Name, doses, how many times/day, duration, side ef-
fect.)
- Allergy to drugs or type of food or dust ?
11- Family History :

- Chronic diseases in the family (HTN - DM - asthma -IHD - hyperlipidemia -
blood diseases)
- Genetic diseases
30 - Cancer
2. History of Palpitations .. cont.
12-social History:
- Educational level
- Occupation
- Smoking : either passive or active ( ask about type , duration, no of
packs per day then calculate it in pack - year ) or Ex – smoker ( for how
long?)
- Alcohol &Drug Abuse
- Travelling & Immunization
- Sexual contact
- Diet and Physical activity
13- Differential Diagnosis :

Feature Suggests
Heart misses and thumps Ectopic beats
Worse at rest Ectopic beats
Very fast, regular SVT(VT)
Instantaneous onset SVT(VT)
Offset with vagal maneuvers SVT
Fast and irregular AF
Forceful and regular (not fast) Awareness of sinus rhythm(anxiety)
Sever dizziness or syncope VT
Preexisting heart failure VT
31
3- History of Shortness of Breath (Dyspnea)
1-Personal Data :
2-Chief Complaint (CC) :

Shortness of breath , Ask about the duration of symptoms (minutes /days /
moths / years)
3- History of Presenting Illness(HPI) :

Onset
-Did it start suddenly or gradually?
Time course
-Is it continuous or intermittent?
- If intermittent :
-How many attacks /day?
-Duration between each attack?
Exacerbating and alleviating factors
-Is there any aggravating factor?( exercise, emotion, smoking, dust
and infection)
-Is there any relieving factor? ( rest , bronchodilator)
-What was doing before the attack?( exercising ,climbing , sitting rest)
Severity
-Is it severe enough to interfere with daily activities?
Progression
-Is it getting worse or does it stay the same?
4- Associated Symptom :
-CVS associated symptoms :(Chest pain , Dyspnea , Orthopnea, PND , Palpi-
tations , Syncope , Ankle swelling , Easy fatigue , Intermittent claudication ,
Cold extremities , Cyanosis)
-Respiratory associated symptoms:( Wheeze , Cough , Sputum , Hemoptysis ,
Chest pain , Dyspnea , Hoarseness of voice, Sore throat )
5- risk factor
• Hx contact with sick patient
• Hx of psychiatric illness
• Hx of upper respiratory tract infection 3 weeks back
1. Fever
2. Fatigue
3. Weight loss
4. Loss of appetite
32 5.Night sweating
3- History of Shortness of Breath (Dyspnea) .. cont.
• DO you have :( Vomiting , Nausea , Heart burn , Abdominal pain ,Change bow-
el habit ) (GIT)
• DO you have :( Headache, Neck pain, Visual disturbance, Seizures , Limb
weakness ) (CNS)
• DO you have :( Dysuria , Hematuria , incontinence , polyuria ) (GU)
•DO you have :( Joint pain , Bone pain , Anemia ) ( Hematology + Rheumatol-
ogy )
•DO you have :( Bruising, Itchiness ,Color changes, Rashes, Swelling) ( Skin)

•Any previous history of similar attack?
•Any Chronic disease (DM-HTN-IHD-Asthma–TB-liver-Renal-IBS) ?
•Previous hospitalization (why, when )?

• Any Previous operations? (type, when, complication, outcome)
.•Any Blood transfusion.?

• Any drug the patient is using?
If using ask about: ( Name, doses, how many times/day, duration, side effect.)
• Allergy to drugs or type of food or dust ?

• Family history of similar symptoms
• Chronic diseases in the family (HTN - DM - asthma -IHD - hyperlipidemia -
blood diseases)
• Genetic diseases
• Cancer
12-social History :
- Educational level
- Occupation
-Smoking : either passive or active ( ask about type , duration, no of packs per
day then calculate it in pack - year ) or Ex – smoker ( for how long?)
- Travelling and Immunization
- Sexual contact
-Diet &Physical activity
33
Angina /MI
1-dyspnea associated with chest tightness
Cardiac Left ventricular failure
1. Orthopnea
2.PND
Pulmonary embolism (PE)
1. Sudden onset
2. Pleuritic chest pain
3. History of DVT, long embolization, blood dis-
ease , previous PE
Pneumothorax
1. Sudden onset
2. Unilateral pleuritic chest pain
3. History of trauma or chronic airway disease
Pneumonia
1. Acute sudden onset fever
2. Cough productive of thick sputum
Respiratory 3. Pleuritic chest pain
asthma
1. Dry cough
2. Wheezing
3. Chest tightness
4. Symptoms are worse at night
5. Dyspnea triggered by emotion , exercise ,in-
fection .
Chronic bronchitis &emphysema (COPD)
1. Heavy smoker
2. Cough associated with increasing sputum in
the morning .
3. Suffer from recurrent lung infection
1-Anemia
others
2- Anxiety
34
Differential diagnosis (based on time of onset) : (reference talley p 132 )
Cardiac disease:
Chronic: Cardiac failure, valvular heart disease, cardiomyopathy
Acute: Arrhythmia, myocardial infarction, pericardial effusion, constric-
tive pericarditis
Pulmonary disease:
Sudden: Pneumothorax, pulmonary embolism
Acute: Asthma, pneumonia, pulmonary edema
Chronic: COPD, bronchiectasis, cystic fibrosis, pulmonary hypertension.
Others:
Chronic: Anemia
Acute :Metabolic acidosis,
anaphylaxis, anxiety
- Pulmonary function testing

Causes of orthopnea: (spirometry) : is definitive
1.Cardiac failure “most common”. diagnostic test for airway ob-
struction disease.
2. Massive ascites. - airway obstruction disease
3. Pregnancy. are: {Chronic bronchitis& em-
physema( both called COPD),
4. Bilateral diaphragmatic paralysis.
Asthma, Bronchiectasis }
5. Large pleural effusion.
6.Severe pneumonia. reference step up p 70
FEV1/FVC ratio
less than 0.70
indicates airway
obstruction
35
4- History of Syncope
1-Personal Data :

Syncope (transient loss of consciousness) Ask about the duration of symptoms
(minutes /days /moths / years)
3- History of Presenting Illness(HPI) :

Duration
- When did it start?
- How long the episode last?
Onset
- Did it start sudden or gradual ?
*Sudden (cardiac syncope, Tonic-clonic (grand mal) seizure)
Time course
-How many attacks?
*Most people have one episode (Vasovagal syncope)
-What was the time between each attack?
-How many minutes each attack last for?
~Pre ictal:
•Do you black out or feel dizzy when you stand up quickly? (Postural hy-
potension)
•Did the episode occur during one of the following?
-When you have exercise. (Lf ventricular outflow obstruction, aortic
stenosis)
-When you get up to pass urine at night or in specific situations indi-
cating situational syncope. (Micturition syncope)
•Did you get any warning?
-Nausea, cough, constipation, being in a stuffy room (Vasovagal epi-
sode), strange smell or feeling of Deja-Vu (Aura and seizure)
~During attack:
•Have you injured yourself?
- Injury common in (seizure)
- Injury uncommon (Postural hypotension, vasovagal syncope)
•Did you pass urine during the episode? Did you bite your tongue? (Seizure)
•Did anyone saw an episode and notice jerky movement? (Seizure)
~Post ictal:
• Did you wake up feeling normal, drowsy or weakness?
- Normal? (Cardiac syncope)
- Drowsy & confusion? (Seizure)
- Weakness? (stroke)
36
4- History of Syncope .. cont.
2- Associated Symptoms :
- associated with: Aura, nausea, vomiting, neck stiffness, weakness, convul-
sion, tongue biting, rolling of the eye, self-injury, numbness or tingling, and/
or memory loss.
- CVS associated symptoms :(Chest pain, Dyspnea, Orthopnea, PND, Palpita-
tions , Syncope , Ankle swelling , Easy fatigue, Intermittent claudication, Cold
extremities, Cyanosis)
- DO you have :( Headache, Neck pain, Visual disturbance, Seizures , Limb
weakness ) (CNS)
5- risk factor :
• Cardiovascular disease is a major risk factor for syncope
• History of stroke or transient ischemic attack.
• Lower body mass index.
• Increased alcohol intake
1. Fever
2. Fatigue
3. Weight loss
4. Loss of appetite
5. Night sweating
• Do you have:( Wheeze, Cough, Sputum, Hemoptysis, Sore throat ) (Resp)
• Do you have :( Vomiting, Nausea, Heart burn, Abdominal pain, Change bowel
habit ) (GIT)
• Do you have :( Dysuria , Hematuria , incontinence , polyuria ) (GU)
•Do you have :( Joint pain, Bone pain, Anemia ) ( Hematology + Rheumatology )
• Do you have :( Bruising, Itchiness, Color changes, Rashes, Swelling) ( Skin)

• Any previous history of similar attack?
• Any Chronic disease (DM- HTN- IHD- Asthma – TB-liver- Renal- IBS ) disease ?
• Previous hospitalization (why, when )?

•Any Blood transfusion.?

• Any drug the patient is using?
If using ask about: ( Name, doses, how many times/day, duration, side effect.)
• Allergy to drugs or type of food or dust ? 37
• Chronic diseases in the family (HTN - DM - asthma -IHD - hyperlipidemia
- blood diseases)
•Cancer
If syncope occurs with
12-social History : exertion ,assess for
life threatening causes
- Marital status , if there any children such as aortic stenosis
- Educational level or hypertrophic car-
- Occupation diomyopathy .
- Smoking : either passive or active ( ask about type ,
duration, no of packs per day then calculate it in reference step up p 229
pack - year ) or Ex – smoker ( for how long?)
- Sexual contact
- Diet &Physical activity
13- Differential Diagnosis : (reference step up p229-231)

1-Most common cause of syncope
2- Onset in teens or 20s
3- Occurs when the patient is upright (sitting up or standing). Do
not occur when the patient is recumbent.
Vasovagal
4- Occurs in response to emotional distress, e.g. sight of blood
syncope
5-Associated with nausea, diaphoresis, lightheadedness and dimming of
vision
6- Injury uncommon
7- Unconsciousness brief, no neurological signs on waking
1-Sudden loss of consciousness without prodromal symptoms
2-causes:
A. Cardiac arrhythmias are the most common cardiac causes of syncope.
B. Obstruction blood flow (aortic stenosis, hypertrophic cardiomyopathy) .
Cardiac 3-Regardless of the patient’s posture
syncope 4-Recovery is equally quick
1- It may associated with exertional activity .
6-Chest pain may occur if the patient has ischemic heart disease or aortic
stenosis .
7- History of cardiac disease & rapid palpitations
1-Occur when the patient is upright (sitting up or standing). do not occur
when the patient is recumbent
2-causes
Postural -Could be due to diabetes mellitus and Parkinson’s disease
hypotension -Drugs (e.g. diuretics, vasodilators, tricyclic antidepressant, antipsy-
chotics.)
3- Aging is associated with an increased prevalence of orthostatic hypoten-
sion
38
1-Sudden loss of consciousness—a fall
to the ground
2- Associated with prodromal symp-
toms (aura)
3- Tonic-clonic (grand mal) seizure
4- Patient then becomes flaccid and
comatose 5- Postictal confusion and
drowsiness are characteristic
6-Tongue biting, vomiting, apnea and
incontinence(urine and/or feces).
Seizures
7-Could be due to
-Metabolic and electrolyte distur-
bances (hyponatremia, hypogly-
cemia or hyperglycemia), Intoxi-
cations, Infections.
- Ischemia (common cause of sei-
zure in elderly patients)
- Increased ICP— e.g., due to
trauma, Mass lesions (brain me-
tastases), Missing drugs
1-Most antihypertensive drugs, but
especially calcium channel blockers
(verapamil, diltiazem)
Drug
2-Beta-blockers
3- Digoxin
4- Antiarrhythmic
1-Metabolic causes (hypoglycemia,
Others hyperventilation)
2- Hypovolemia (e.g: hemorrhage)
Two ways to differentiate be-

tween seizure and syncope :
1- In seizure, duration of
unconsciousness tends to be
longer . in syncope loss of con-
sciousness is momentary .
2-In syncope , bladder control is
usually retained .
but in seizure it is often lost .
39
History Example:
A 55 Y old male smoker known case of HTN on antihypertensive drugs, ad-
mitted to ER complaining of severe chest pain for the last 20 minutes. The
pain started while the patient was carrying heavy table, started suddenly,
central, continuous, radiating to his left shoulder and jaw, was severe that
affected his daily activity. He can’t climb more than 1 floor. The pain in-
creased by exercise & heavy meals, relived by rest. He had similar attack 2
months ago. He has orthopnea, sweating during attack, no cough, no PND,
no edema; he denies fever, fatigue, and night sweat, loss of weight and loss
of appetite. Other systemic review was unremarkable. He is compliant to
his antihypertensive medication. He doesn’t have any other chronic illness-
es and never done a surgery or blood transfusion. He is allergic to egg. No
family history of similar or chronic illnesses.
Summary of history :
After you take history as above, you will write it down; I will show you an
example of a chest pain patient, a real one! !
Summery contains (Age, gender, admission, chief complain and duration,

known illness, important positive, important negatives, brief drug history
and most important risk factor).
Summary:
A 55 Years old male patient, smoker, known case of hypertension, compli-
ance to his medication, admitted to ER complaining of severe chest pain
for the last 20 mints. The pain is central, continuous, radiating to his left
shoulder and Jaw; He had similar attack 2 months ago. He has orthopnea,
no PND, edema and fever .
40
CARDIOVASCULAR EXAMINATION
(WIPPPER )
• Wash your hand
• Introduce yourself
• Take permission
• Ensure the privacy
• Position the patient at 45 degree for JVP assessment
• Exposure all the chest area
• Be at the right side the patient
(ABCDEV)
Appearance : looking well , ill or comatose
Body built : cachectic ,underweight , average , overweight , obese
- cause of cachectic : 1\ malignancy 2\ sever cardiac failure (
cardiac cachectic )
Color : normal , cyanosis , jaundiced , pale
Deformity or distress
- Some syndromes which are associated with specific cardiac dis-
eases as: Marfan syndrome, Down syndrome, Turner syndrome.
Environment : things connected to the patient (IV line ,urinary cathe-
ter , drain , O2 mask , etc )
Vital sign : BP , Pulse , RR , Temperature , O2 saturation ,
GENERAL CARDIOVASCULAR EXAMMINATION :

Make sure to check both hands and arms for clinical signs.
Nails:
1) Clubbing :
Definition: increase in soft tissue deposition in the distal part of
fingers or toes.
41
Common causes of clubbing
CVS RESPIRATORY
1/Cyanotic congenital heart disease 1/ lung cancer .
2/Infective endocarditis 2/ chronic pulmonary suppuration .
uncommon causes of clubbing
RESPIRATORY GIT
1/ cystic fibrosis 1/ cirrhosis
2/ asbestosis 2/inflammatory bowel disease
3/ coeliac disease
2) Splinter Hemorrhage:
o Definition linear hemorrhages lying parallel to the long axis of the nail.
Causes:
• Trauma.
• Infective endocarditis
3) Peripheral cyanosis .
HANDS & WRIST:

1) Janeway lesions :
Non tender erythromatous maculopopular lesions containing bacteria occur
rarely in palms or pulps of the fingers in patient with infective endocarditis.
2) Osler’s nodes:
These are red raised tender nodules on the pulps of the fingers or toes or in
the thenar or hypothenar eminence.They are rare manifestation of infective
endocarditis.
3) Tendon xanthomata:
Yellow or orange deposits of lipid in tendons of the hand or arms which occurs
in type II hyperlipidemia.
4) Palmar xanthomata and tuboeruptive xanthomata:

Occur on the elbow and knee and it occurs in type III hyperlipidemia.
5) Muscle wasting.
6) pallor
42 Tendon xanthomata
WRIST:
• The arterial pulse :
Take the pulse from the radial artery, assess the following features:
1) Rate: normally, 60-100 beat/min
2) Rhythm: can be regular or irregular
CAUSES OF BRADYCARDIA AND TACHYCARDIA

BRADICARDIA
regular rhythm irregular rhythm
• physiological (athletes , during sleep ) • atrial fibrillation
• drug ( beta blocker , digoxin , etc ) • frequent ectopic beats
• hypothyroidism • second -degree AV -block
TACHYCARDIA
regular rhythm irregular rhythm
• hyper dynamic circulation (emotion,
• myocardial ischemia
fever, pregnancy, anemia, thyrotoxico-
• hypertensive heart disease
sis)
3) Volume and character: Best determined at the carotid or brachial artery.

However,
the collapsing pulse of aortic regurgitation and the pluses alternates of left
ventricular failure may be assessed at the radial artery.
ARTERIAL PULSE CHARACTER

type of pulse: cause:
anacrotic (small volume, slow up-
aortic stenosis
take ,notched wave on upstroke )
plateau (slow upstroke ) aortic stenosis
bisferiens (anacrotic and collapsing ) aortic stenosis and regurgitation
• aortic regurgitation
• hyper dynamic circulation
collapsing
• patent ductus arteriosus
• peripheral arteriovenous fistula
• aortic stenosis
small volume
• pericardial effusion
alternans (alternating strong and
left ventricular failure
weak beats )
4) Radio-radial delay: usually due to atherosclerotic plaque, aneurysm, steno-

sis of the
subclavian artery, or dissection of the aorta.
5) Radio –femoral delay: Usually due to coarctation of the aorta.
43
ARM:
•Palmar and Tuberuptive Xanthomata over elbow or knee ( type 3 hy-
perlipidemia )
Blood Pressure :-
A. Korotkoff sounds:
KI : the first heard sound (a thud).
KII : The sound increase in intensity (a blowing or swishing sound).
KIII : the sound then decrease (a softer sound thud).
KIV : A softer blowing sound that disappears.
KV : The last heard sound.
B. MEASURING THE BLOOD PRESSURE WITH THE SPHYGMOMANOMETER:

- Ensure the cuff of sphygmomanometer is the proper size for patient.
- Wrapped the cuff around the upper arm of the patient with the bladder
centralized
over the brachial artery.
- Detect the anatomical site of the brachial artery which is medial to biceps
tendon and
lateral to medial epicondyle and place the diaphragm of stethoscope there.
- Inflate the cuff and don’t forget to palpate the radial artery and stop the
inflation when the radial pulse disappears, this to avoid the auscultatory gap
which is the gap between Kl and Kll (absence of sound).
- Start to deflate slowly and the first sound is Kl and it indicates the systolic
blood pressure and the last heard sound is KV and in some case KlV and it
indicates the diastolic blood pressure .
- Normally, there is a difference in BP between the two arms about 10 mmhg
and between arms and legs about 20 mmhg .
CATEGORY SYSTOIC(mmHg) DIASTOIC(mmHg)
optimal <120 <80
normal 120-129 80-84
high normal 130-139 85-89
mild hypertension 140-159 90-99
moderate hypertension 160-179 100-109
sever hypertension >180 >110
C. POSTURAL HYPOTENSION:
A fall of more than 15 mmHg in systolic blood pressure or 10 mmHg in dia-
stolic pressure on standing.
Causes of postural hypotension (HANDI):
- Hypovolemia (e.g. dehydration, bleeding) and Hypopituitarism.
- Addison’s disease.
- Neuropathy – autonomic (e.g. diabetes mellitus), amyloidosis, shy-drager
syndrome).
- Drugs (e.g. vasodilators and other antihypertensives)
44
- Idiopathic orthostatic hypotension (rare progressive degeneration of the au-
tonomic nervous system, usually in elderly men).
D. PULSUS PARADOXUS:
It’s a decrease in systolic blood pressure during inspiration more
than 10 mmhg. (normally decrease by a maximum of 10 mmhg). To assess
pulses paradoxes, stop the deflation when Kl is heard and ask the patient to
take a deep breath then observe the changes in systolic blood pressure with
inspiration.
The causes : Cardiac tamponade, acute severe asthma,and uncommonly con-
strictive pericarditis, right ventricular infarction, and pulmonary embolism.
FACE :
Look for the following :
1- Jaundice: you can see it in the sclera of the eye
CVS causes: CHF, hepatic congestion or prosthetic heart valve.
2- pallor : you can see it in the conjunctiva of the eye
3- Xanthelasma:
Definition: An intracutaneous yellow cholesterol deposit around the eye.
Causes: occurs as normal variant or in type II or III hyperlipidemia.
4- Corneal arcus:
Caused by precipitation of cholesterol crystals at the periphery of the
cornea.
5- Mitral faces (Malar flush):
Appearance: Rosy cheeks with bluish tinge.
Cause: dilatation of malar capillaries.
Occurs in:
A. Pulmonary HTN.
B. Low cardiac output as in mitral stenosis.
6) The mouth:
- High arched palate: this occurs in Marfan’s syndrome which is associated
with mitral valve prolapse and aortic dissection.
0 The teeth : notice if they are diseased as they can be a source of organ-
isms responsible for infective endocarditis or rheumatic heart disease
- Tongue and lips for central cyanosis.
- Petechiae in the mucosa that may indicate infective endocarditis
45
Mitral faces Xanthelasma
NECK :
A. CAROTID ARTERIES:
These arteries, found medial to sternomastoid muscle, give us information
about the aorta and left ventricular function.
**Never palpate both carotid arteries together (it will lead to syncope).
B. JUGULAR VENOUS PRESSURE (JVP):
It is a measurement of Rt ventricular end diastolic pressure. The center of
the right atrium lies 5 cm below the zero point. So its importance is in that
it tells us about right arterial and right ventricular function.
Normal JVP: < 3-4 cm above sternal angle.
Method:
1- Position the patient at 45° in good light.
2- Ensure the neck muscles are relaxed by resting the back of the head on a
pillow.
3- Identify the internal jugular pulsation, if necessary, by means of hepato-
jugular reflex.
4- Identify the height and character of the pulsation.
5- The height is measured by using two rulers, one is put vertically on the
sternal angle, while the other is put on the horizontal plane from the maxi-
mum height of the jugular pulsation. The point where both rulers meet is the
reading of the JVP.
Important signs:
1- Abdominojugular Reflex
(aka hepatojugular) :Is done by applying
a firm pressure on the epigastric area
(ask patient if there is any abdominal pain)
for 10 second. This will increase the venous return to the heart causing
a transient increase in JVP. This is a normal reflex. However, in right ven-
tricular failure, the JVP may remain elevated for the entire duration of
the compression (persistent elevation >4cm is indicative of right ventric-
ular failure).
2- Kussmaul’s Sign:
Rise in JVP during inspiration.
causes : constrictive pericarditis, sever heart failure, right ventricular
46 infarction, and pulmonary embolus .
DIFFERENCE BETWEEN CAROTID AND JUGULAR PULSATION
CAROTID JUGULAR
Rapid outward movement Rapid inward movement
Two peaks per heartbeat (complex
One peak per heartbeat
waves)
Palpable Visible not palpable
Independent of respiration, position or Dependent of respiration ( decrease
abdominal pressure (no hepatojugular during inspiration), position and abdomi-
reflux) nal pressure
It can be obliterated and after relief of
It fills from below. (artery)
pressure it fills from above. (vein)
CAUSES OF AN ELEVATED CENTRAL VENOUS PRESSURE (HIGH JVP):

1- Right ventricular failure.
2- Tricuspid stenosis or regurgitation.
3- Pericardial effusion or constrictive pericarditis .
4- Superior vena cava obstruction.
5- Fluid overload.
6- Hyper dynamic circulation.
CHARACTER OF JVP (PATTERNS OF WAVES):

~ There are 2 positive waves in normal JVP:
1- a wave:
It coincides with right atrial systole. Also coincides with 1st heart
sound and precedes the carotid pulsation. It is caused by atrial con-
traction.
2- v wave:
It coincides with ventricular systole. It is caused by atrial filling in
the period when the tricuspid valve remains closed during ventricu-
lar systole.
~ There are 2 descents (negative waves) in normal JVP:
1- x descent :
Comes after the a wave and caused by atrial relaxation.
If it was :-
Absent: Atrial fibrillation,
Exaggerated: Acute cardiac tamponed, constrictive pericarditis
2- y descent:
Comes after the v wave and is caused by rapid ventricular filling
when the tricuspid valve opens.
If it was :-
Sharp: Sever tricuspid regurgitation, constrictive pericarditis
Slow: Tricuspid stenosis
47
Finally, the c wave is a small usually non-visible positive wave which comes
right after the a wave. It is caused by the transmitted pulsation from the ca-
rotid artery.
Abnormalities of JVP waves:

• Cannon a wave:
occurs when the right atrium contracts against a closed tricuspid valve.
This happens in :
Complete Heart Block
• Giant a wave:
This is a large but not an explosive a wave with each beat. It occurs when
the right atrial pressure is raised because of the:
1- Obstruction in the outflow (tricuspid/pulmonary stenosis).
2- Elevated pressure in pulmonary circulation.
• Absent a wave:
This is seen in atrial fibrillation because of the loss of proper atrial con-
tractions.
• Large v wave:
Occur in tricuspid regurgitation.
48
Precordium Examination
• Inspection:
1. Scars : median sternotomy , lateral thoracotomy, sub mammary.
2. Skeletal abnormalities : such as pectus excavatum (funnel chest ) , Pectus
carinatum ( pigeon chest ) or kyphoscoliosis (a curvature of the vertebral
column) . Skeletal abnormalities such as these, which may be part of Marfan’s
syndrome .
3. pacemaker (cardioverter-defibrillator box )
4. Visible abnormal pulsations of apex beat or over the pulmonary artery in-
cases of severe pulmonary hypertension.
• Palpation:
1) The apex beat
The position of the apex beat is defined as the most lateral and inferior point
at which the palpating fingers are raised with each systole.
- we should comment on the apex beat’s position , character and size .
Its normal position is in the fifth left intercostal space, 1 cm medial to the
midclavicular line.
Its size is of a 20 cent coin and its character is that it normally gently lifts the
palpating fingers with each systole . . abnormal apex beat may be a sign of
underlying pathology .
Apex beat: abnormalities found

on palpation, causes of impalpable
HILT:
Heaving, Impalpable, Laterally
displaced, Thrusting/ Tapping
If it is impalpable, causes are

COPD:
COPD , Obesity, Pleural, Pericar-
dial effusion, Dextrocardia
In many patients the apex beat may not be palpable. This is most often
due to :
Apex Beat Displacement Difficult to palpate
Cardiomegaly Thick chest wall as in obesity
Chest wall deformity Emphysema
Pericardial effusion Pericardial effusion
Mitral regurgitation Shock (or death)
--- Dextrocardia
49
character of the apex
Definition indicate
beat
The pressure loaded apex forceful and aortic stenosis or hyper-
beat sustained impulse tension.
The volume loaded displaced, diffuse, advanced mitral regurgi-
(thrusting) apex beat non-sustained impulse. tation
The double impulse apex two distinct impulses are hypertrophic cardiomyop-
beat felt with each systole athy
the first heart sound is mitral or very rarely
The tapping apex beat
actually palpable tricuspid stenosis.
1) thrills.
These are palpable murmurs (grade 4 or more) , caused by turbulent blood
flow through abnormal valves
Two type :
systolic thrill: a thrill that coincides in time with the apex beat .
Diastolic thrill : a thrill that does not coincide with the apex beat .
The thrills feel with the palm of the hand over the valves areas, start by
mitral, tricuspid, aortic and pulmonary valves respectively.
2) parasternal heave :
Palpable impulses felt when the heel of the hand is
rested just to the left of the sternum , they are caused by right ventricular
enlargement or severe left atrial enlargement .
Percussion :
Not important in CVS examination.
50
Auscultation :
The stethoscope has two parts :
1-the bell : designed for amplifying low pitched sound .
2-the diaphragm : designed for higher pitched sound .
Auscultation sequence :
1- Mitral area with the bell and then by the diaphragm .
2- Tricuspid area with the diaphragm .
3- Pulmonary area with the diaphragm .
4- Aortic area with the diaphragm .
Closure sequence of
Heart valves
Many Things Are
Possible”:
Mitral
Tricuspid
Aortic
Pulmonary
Normal heart sounds :

1- First heart sound (S1) :indicate the beginning of systole and has two com-
ponents :
• Mitral valve closure
• Tricuspid valve closure
2- The second heart sound (S2): which is softer, shorter and at a slightly
higher pitch than the first, indicate the beginning of diastole and has two
components :
• Aortic valve closures.
• Pulmonary valve closures.
Physiological splitting ( the closure of the aortic valve earlier than the pulmo-
nary valve )
Occurs because the pressure of systemic circulation is higher than the pres-
sure of pulmonary circulation .
This splitting is increase by inspiration . (because increased venous return to
the right ventricle which further delay pulmonary closure ) .
Palpation of the carotid artery while

auscultating will indicate the time of
systole and make distinguishing the
heart sounds easier (S1 precedes the
pulse while S2 follows the pulse ) .
51
3)- Third heart sound (S3) : caused by rapid filling of the ventricles af-
ter opening of AV valves . it is a low pitched mid diastolic sound .
It lead to the impression of gallop rhythm ( resembling a galloping horse
) which is a triple rhythm consists of 3 heart sound . it occurs physiologi-
cally in children , young adults , and pregnancy .
Abnormalities of the heart sounds :

1- alternation in intensity
2- splitting
3- extra heart sound
4- additional sound
5- murmurs
Alternation in intensity :
Loud :
• when the mitral or tricuspid valve cusps remain wide open at the
end of diastole and shut forcefully with the onset of ventricular sys-
tole. This occurs in mitral stenosis
first heart sound • tachycardia :due to reduced diastolic filling time
(S1) Soft :
• first-degree heart block :due to a prolonged diastolic filling time .
• left bundle branch block : due to delayed onset of left ventricu-
lar systole
•mitral regurgitation
loud aortic component (A2):
• systemic hypertension
• Congenital aortic stenosis .
loud pulmonary component (P2):
second heart
• pulmonary hypertension
sound (S2)
• pulmonary stenosis
soft (A2) :
• aortic valve calcification
• aortic regurgitation
Splitting :
First heart sound (S1) Splitting :
Splitting of the (S1) is usually not detectable
clinically; however, when it occurs it is most often due to complete
right bundle branch block.
52
second heart sound (S2) Splitting: occurs in 3 patterns
Increased normal splitting fixed splitting reversed splitting
P2 occurs first and splitting oc-
wider on inspiration no respiratory variation
curs in expiration)
• left bundle branch block : due
to delayed left ventricular depo-
• This is caused by an
• Right bundle branch larization
atrial septal defect where
block • severe aortic stenosis, coarc-
equalization of volume
• Pulmonary stenosis tation of the aorta :due to de-
loads between the two
• Ventricular septal defect layed left ventricular emptying
atria occurs through the
• Mitral regurgitation large patent ductus arteriosus :
defect .
due to increased left ventricular
volume load
Pathological Extra heart sounds :

Third heart sound (S3) Fourth heart sound (S4)
Itis a late diastolic sound pitched slightly
It is a low-pitched mid-diastolic sound
higher than the S3. this is responsible for
, more easily heard with the bell of the
the impression of a triple (gallop) rhythm,
stethoscope.
It is due to a high-pressure atrial wave re-
Usually pathological after age 40 , it is due
flected back from a poorly compliant ven-
to reduced ventricular compliance.
tricle .
A left ventricular (S4) occurs when left
left ventricular S3 :
ventricular compliance is reduced due to :
louder at the apex , and on expiration.
• Aortic stenosis,
Occurs in :
• Acute mitral regurgitation
• left ventricular failure and dilatation
• Systemic hypertension,
• aortic & mitral regurgitation
• Ischemic heart disease ( sound may be
• ventricular septal defect
the only physical sign in angina or MI )
• patent ductus arteriosus.
• Advanced age.
right ventricular S3 : is louder at the left
A right ventricular( S4) occurs when right
sternal edge and with inspiration.
ventricular compliance is reduced due to :
Occur in :
• Pulmonary hypertension
• right ventricular failure
• Pulmonary stenosis.
• constrictive pericarditis.
53
Additional sounds :
high-pitched sound
that occurs after S2.
Best heard at the lower
opening snap It is due to the sudden In mitral stenosis.
left sternal edge
opening of the mitral
valve .
In congenital aortic Best heard at the aortic or
systolic ejec- is an early systolic
or pulmonary ste- pulmonary and left sternal
tion click high-pitched sound .
nosis edge areas
non-ejection high-pitched sound Best heard at the mitral
In Mitral prolapse
systolic click heard during systole . area.
Superficial scratching
Best heard at the lower
sound with systolic &
left sternal edge when
diastolic components
Pericardial rub In Pericarditis patient is sitting up and
, caused by movement
breathing out using the
of inflamed pericardial
diaphragm
surfaces
Murmurs:
Are continuous sounds caused by turbulent blood flow.
If there is a murmur, you have to stop and comment about:
1-site
2-Timing + Sub timing
3- Area of greatest intensity
4-Radiation
5-Grading
6-Dynamic maneuvers
Area of greatest
Timing Sub Timing Lesion Radiation
intensity
Mitral regurgitation Mitral area To the Axilla
Tricuspid regurgitation Tricuspid area
Pan
Left lower sternal
Ventricular septal defect
edge
Aortic stenosis Aortic area To the neck
Systolic Pulmonary stenosis Pulmonary area
Mid Or Hypertrophic Left lower sternal
Ejection cardiomyopathy edge
at left mid to upper
Atrial septal defect
sternal border
Late Mitral valve prolapse Mitral area
Aortic regurgitation Aortic area
Early
Pulmonary regurgitation Pulmonary area
Diastolic
Mitral stenosis Mitral area
Mid
Tricuspid stenosis Tricuspid area
Systolic Patent ductus arteriosus Infraclavicular area
and - Arteriovenous fistula Right supraclavicular
54 diastolic -Venous hum fossa
Grading:
Grade 1: difficult to be audible.
Grade 2: soft but can be heard. Murmurs : systolic vs.
Grade 3: moderate, without thrill. diastolic
Grade 4: loud with thrill. PASS: Pulmonic & Aor-
Grade 5: very loud, thrill can be palpable. tic Stenosis = Systolic
Grade 6: audible murmur without stethoscope.
PAID: Pulmonic &Aortic
Insufficiency = Diastolic
Dynamic maneuvers: (tally + batch 32)
Anything increases venous return will increase
the murmur due to volume overload, and anything decreases venous return
will decrease the murmur due to the reduction in blood flow except in Hyper-
trophic cardiomyopathy (HCM) and Mitral Valve Prolapse (MVP).
1-Respiration:
Inspiration: increases the intensity of right site murmurs.
Expiration: increases the intensity of left site murmurs.
2-Valsalva maneuver:
“Can you strain (hold your breath, contract your abdominal muscles and
push)”, this decreases venous return.
3-Hand grip:
“Can you make a fist and hold it strongly”, this decreases murmur.
4-Squatting to standing:
Stand rapidly from the squatting position, this decreases venous return.
5-Standing to squatting:
Sit rapidly from standing on feet flexing your knees, this increases venous re-
turn due to the use of the muscle pump.
Hand grip
Valsalva maneuver Squatting or leg raise
(reduction in pres-
(decrease preload) (increase preload)
sure gradient)
Mitral regurgitation
Aortic stenosis
Mitral valve prolapse

Hypertrophic cardio-
myopathy
55
To complete the examination:
•The abdomen:
o Pulsatile liver “Tricasped Regurgitation ”
o Hepatomegaly “Congestive Heart Failure ”
o Splenomegaly “infective endocarditis”
o Ascites “CHF”
o Aorta “aortic aneurysm”
o Auscultate over the femoral artery “AR signs”
•The back:
o Deformities “kyphosis - scoliosis”,
o Sacral edema,
o Percuss for pleural effusion “ CHF”
o Auscultate the bases of the lungs for crackles “CHF”
•Lower limbs:
o Pulses : femoral, popliteal, posterior tibial, dorsalis pedis
o Peripheral vascular diseases signs “PVD” (6 Ps): pain, pallor,
pulseless,
paralysis, paresthesia& perishing cold/poikilothermic
o Edema: determine its level
o DVT : calf swelling and tenderness
Murmurs: systolic types SAPS:

Systolic
Aortic
Pulmonic
Stenosis
Systolic murmurs include aortic
and pulmonary stenosis. Similarly,
its common sense that if it is aortic
and pulmonary stenosis it could
also be mitral and tricuspid regur-
gitation.
56
Summary
57
58
Respiratory System Chapter
Rawan Osama Mirza
Ebtihal Tariq Yamani
Salwa Obed AlOmairi
Bassam Adel Aljabri
Revised by:
Abdullah Bakur Bannani
60
1- HISTORY OF COUGH
Introduce yourself, take permission from the patient to take the history.
1-Personal Data:
Name, Age, Gender, Nationality, Route and Time of Admission (Through OPD
or ER?).
2-Chief Complaint (CC):

Cough, Its duration (minutes/hours/days/months/years).
3-History of Presenting Illness (HPI):

Onset:
When did it start? suddenly
Cough is an abrupt high flow of air against closed vocal cords which
opens up after few milliseconds .It can not start gradually
Duration:
To know the problem is acute or chronic;
How long have you had the cough?
Course:
intermittent
No one can cough continuously , physiologically it cant happen ,
with cough there is transient increase in venous return and increase
in intrathoracic pressure followed by higher cardiac output , If
cough persists person can pass out
*Note: if it’s intermittent ask about frequency.
frequency indicates severity
Frequency:
How many attacks per day? Time between attacks?
Progression:
Does it increase or decrease with time?
Severity:
Does it affect your sleep and daily activities? (Estimate from 1 to
10).
Timing:
Does it relate to a specific time? (morning, after meals, particularly
at night (e.g. acid reflux))?
Aggravating and Relieving Factors:
Does anything aggravate (e.g. Perfumes, dust, URTI, cold weather,
exercise)?
Smokes , swings in temperature ( warm body going into cold envi-
ronments and vice versa , pets
or relieve it (e.g. Drugs, Oxygen)?
What non medical label as oxygen is actually a bronchodilator medi-
cations given thorough mask
61
HISTORY OF COUGH .. cont
Character:
-Barking cough (Croup): is a viral infection and It commonly affects
children and worsens at night.
-Whooping cough.
-Dry Cough: from mild environmental irritants, such as smoke, to
disorders or infectious diseases, like asthma, the flu or pneumonia.
Dry cough defensive repulsion of irritant , any inflammation can
cause it , non infectious (asthma ) or infectious
-Productive Cough: ask about (amount, color, odor and blood);
A- Bronchiectasis: yellowish or green, large amount, foul smell
mainly increases in the morning.
B- Pneumonia: yellowish or greenish.
C- Hemoptysis (blood): TB, bronchiectasis, lung abscess.
D- Pulmonary Edema: Pink frothy.
Productive cough is either retained secretions from narrowed airway
(asthma ,COPD ,Bronceactiaisis) or inflammation with subsequent
cell death (infection, malignancy )
4-Associated Symptoms:
RS related symptoms ;(Shortness of breath, chest pain, runny nose, sore
throat, hoarseness, hemoptysis, wheezing).
Upper airway : ( runny , itchy or blocked nose .Post nasal drip .Voice hoarse-
ness .Dry sore throat .Stridor )
Lower airway :( SOB, wheeze , pleuritic chest pain )
5-Risk Factors:
- History of contacting sick pt.
- Hx of travel.
- Smoking; either passive or active (ask about type, duration, No. of packs
per day then calculate it in pack-year) or Ex-smoker (for how long?).
- History of contact with TB pt.
Fever, Fatigue, Weight loss, Loss of appetite and Night sweating.
It reflects ongoing catabolic status ( energy being used more than generated
) not specific ( can occur with chronic infection , malignancy or autoimmune
connective tissue disease )
7-Systemic Review:
-CVS: Chest pain, syncope, orthopnea, PND, ankle edema, intermittent clau-
dication.
-Musculoskeletal: Joints welling, joint pain, skin rash.
-GIT: Vomiting, diarrhea, abdominal pain, distension, constipation, jaundice.
-Urinary tract: Frequency, dysuria, hematuria, nocturia, polyuria, dripping,
62 incontinence.
-CNS: Headache, neck stiffness, visual disturbance, seizures. Weakness or
lack of sensation
-Hematological: Pallor, jaundice, bone pain, bruises.
8-Past Medical History (PMH):

-Any previous history of similar attack?
-Previous respiratory illness (e.g. lung or sinus problems)?
-Any chronic diseases? e.g. Asthma, heart disease, liver disease, renal, HTN
(how long? good or poor compliance to medication?) and DM (which type? Con-
trolled or not? Are there any retinal, renal, vascular, cerebral complications).
-Previous hospitalization (Why and hospital course (investigations, diagnosis,
medications)).
-Chronic use of any medication (e.g. ACE inhibitors ).
9-Past Surgical History (PSH):

-Any previous operations*? (Type, When, Complications, Outcome)
-Any blood transfusion?
*Note: e.g. of related procedures (e.g. bronchoscopy, lung biopsy, spirometry
and cardiac).

Food, drugs, environment, animals.
11-Family History:
-Family history of similar symptoms.
-Chronic diseases (e.g. Asthma or other atopic diseases, COPD, Cardiac diseas-
es, DM, HTN , DVT ,PE).
-Genetic or inherited diseases (e.g. Alpha1-antitrypsin deficiency).
-Cancer (e.g. lung cancer).
12-Social History:
-Marital status, and if there are any children.
-Educational Level.
-Occupation.
-Living Status (where he/she is living).
-Alcohol & Drug Abuse
63
13-Differential Diagnosis (DDx):
System Site Disease
Upper respiratory tract:
• Inhaled foreign body
-Obstruction
Acute cough • Common cold, sinusitis
(<3 weeks Respiratory -Infection
duration): related and •Pneumonia, bronchitis,
others Lower respiratory tract:
exacerbation of COPD
-Infection
•Inhalation of bronchial irri-
-Irritation
tant, e.g. smoke or fumes.
Systems Disease Clues
COPD smoking history.
Reaction to asthma triggers
Asthma wheeze, relief with bron-
chodilators.
history of rhinitis, postnasal
Upper airway cough syn-
drip, sinus headache and
Respiratory drome ( post nasal drip) congestion.
Related
History or known case of
TB, contact with TB patient,
Chronic TB
sick person febrile coughing
cough blood
Bronchiectasis chronic, very productive.
Carcinoma of the lung smoking, hemoptysis.
occurs when lying down
Gastro-esophageal reflux after heavy meal , burning
chest pain.
Others ACE inhibitor medication drug history.
Cardiac failure dyspnea, PND.
variable, prolonged symp-
Psychogenic
toms, usually mild.
Case Summary :
A 54-year-old Saudi male pt. K/C of hypertension on propranolol pre-
sented through ER with a 2-day history of a productive cough with yel-
low sputum, chest tightness, and fever. Physical examination reveals a
temperature of 38.3°C, BP of 150/95 mmHg, heart rate of 85 bpm, and
a respiratory rate of 20 breaths per minute. His oxygen saturation was
95% at rest; lung sounds were distant but clear, with crackles at the left
base. CXR reveals a left lower lobe infiltration
64
HISTORY OF HEMOPTYSIS
Introduce yourself, take permission from the patient to take the history.
1-Personal Data:
Name, Age, Gender, Nationality, Route and time of Admission (Through OPD or
ER?).

Coughing blood, Its duration (minutes/hours/days/months/years).

Onset:
When did it start? gradually
Cough can not be gradual is always sudden
Duration:
To know the problem is acute or chronic;
How long have you had it?
Course:
intermittent
*Note: ask about frequency. You cant cough up blood continuously ,
physiologically impossible
Frequency:
How many attacks per day? Time between attacks?
Amount:
-Mild hemoptysis is defined as less than 20 ml in 24 hours, it appears
as streaks of blood discoloring sputum (e.g. Bronchitis).
-Massive hemoptysis is defined as either >500ml of expectorated
blood over a 24-hour period or bleeding at a rate> 100 ml/hour and
represents a medical emergency (e.g. Bronchiectasis).
Color:
It’s frank, bright or dark?
Character:
It’s mixed, streaked or clots?
Aggravating and Relieving Factors:
Does anything aggravate or relieve it?
Progression:
Does it increase or decrease with time?
Severity:
Does it affect your sleep and daily activities? (Estimate from 1 to 10).
Coughing blood is very frightening
Limitation of activity and sleep lack is applicable more to SOB or
pain
65
HISTORY OF HEMOPTYSIS .. cont.
RS related;(Shortness of breath, chest pain, sputum “ask about (amount,
color and odor)”, runny nose, sore throat, hoarseness, wheezing).
5-Risk Factors:
-Smoking: either passive or active (ask about type, duration, No. of packs per
day then calculate it in pack-year) or Ex-smoker (for how long?).
-History of contact with TB pt.
-Any bleeding disorders?
-Any bleeding from other sites?
7-Systemic Review:
dication.
incontinence.
-CNS: Headache, neck stiffness, visual disturbance, seizures.
-If patient is female: LMP? Regular? How many days? Pain with the cycle? Age
of menarche/menopause?

-Previous respiratory illness (e.g. TB, sinusitis, saddle-nose deformity)?
-chronic lung disease or chronic cough sob may reflect underlying bronchiec-
tasis
-Any chronic diseases? Asthma, heart disease (e.g. rheumatic fever), renal,
liver disease, HTN (how long? good or poor compliance to medication?) and
DM (which type? Controlled or not? Are there any retinal, renal, vascular, ce-
rebral complications).
-Previous hospitalization (Why and hospital course (investigations, diagnosis,
medications)).
-Chronic use of any medication (e.g. anticoagulants).
9-Past Surgical History (PSH):

-Any previous operations*? (Type, When, Complications, Outcome)
Any bleeding after surgery ?
*Note: e.g. of related procedures (e.g. bronchoscopy, lung biopsy and cardi-
66 ac).
Food, drugs, environment, animals.
11-Family History:
-Family history of similar symptoms.
-Chronic diseases in the family (e.g. respiratory, heart diseases, renal, DM
and HTN).
-Bleeding disorders (e.g. hemophilia).
-Genetic or inherited diseases (e.g. heredity hemorrhagic telangiectasia).
-Cancer.
12- Social History:

-Educational Level.
-Occupation.
-Alcohol & Drug Abuse.
-Travelling Hx.
Features distinguishing hemoptysis from hematemesis and nasopharyngeal

bleeding:
Hemoptysis: is the coughing of blood originating mostly from the respirato-
ry tract. Hemoptysis should be differentiated from: pseudohemoptysis (e.g.
epistaxis) and hematemesis - vomiting of blood from the gastrointestinal (GI)
tract.
Hemoptysis Hematemesis Nasopharyngeal Bleeding

Mixed with sputum Follows nausea
Occurs immediately after Mixed with vomitus ; fol- Blood appears in mouth
coughing lows dry retching
67
System Disease Clues
Bronchitis Small amounts of blood with sputum.
Frank blood, history of smoking, hoarse-
Bronchial carcinoma
ness.
Large amounts of sputum with blood, foul
Bronchiectasis
smell.
Pneumonia Fever, recent onset of symptoms, dyspnea.
(The above four account for about 80% of cases)
Respiratory Previous TB, contact with TB, HIV positive
related Tuberculosis (TB)
status
Lung abscess Fever, purulent sputum.
Sudden onset, dyspnea, pleuritic chest
Pulmonary embolism
pain.
Pulmonary edema Pink frothy sputum.
Rupture of mucosal
History of sever cough preceding hemopty-
blood vessel after vig-
sis.
orous coughing
Mitral stenosis (sever) Dyspnea
Foreign body History of inhalation, cough, stridor.
Systemic lupus erythe- Pulmonary hemorrhage, multi-system in-
matosus volvement.
Others Pulmonary haemorrhage, glomerulonephri-
Goodpasture’s syn-
tis, antibody to basement membrane anti-
drome
gens.
Wengener’s granuloma-
History of sinusitis, saddle-nose deformity.
tosis
Bleeding diatheses
68
HISTORY OF FEVER
Introduce yourself, take permission from the patient to take the history
1-Personal Data:
Name, Age, Gender, Nationality, Route of Admission (Through OPD or ER?).

fever, Its duration (minutes/hours/days/months/years).

Documentation :
Is it documented or not ?
Through which route ? ( oral/axilla/rectal) .
-Hyperthermia (above 40degree): heat stroke, malignant hyperther-
mia, the neuroleptic malignant syndrome and hypothalamic disease.
-High grade (> 38.3 degree): infective endocarditis, TB.
-Low grade fever (37.8 degree): cold, flu, ear infections.
Frequency ( pattern ):
- Intermittent (temperature falls to normal each day) .
- Remittent (daily fluctuation >2 degree temperature doesn’t return
to
normal) ?
-Relapsing (returns to normal for days before rising again ) ?
-Continuous ( does not remit ) ?
Severity:
Affecting daily activity, sleeping, eating?
aggravating factors or relieving factors :
Do you take any antipyretic ( like paracetamol ) ? or using cold
sponge?
Diurnal variation ? ( at night increases )
These features were not validated in prospective studies , it doesn’t confirm
nor role out any diagnosis
Main bulk of history should be on searching for symptom of underlying disease
4-Associated Symptoms :
Depend on each system.
chills , rigors , joint pain , Rash , headache.
5-Risk Factors :
-Depend on each system.
- History of contacting with sick patient or contact with animals?
- History of known valvular heart disease or prothetic material ?
- History of recent travel ?
- Raw milk ingestion ?
- Sexual history ? ( HIV positive ) 69
HISTORY OF FEVER .. cont.
7-Systemic Review:
- respiratory: Shortness of breath, chest pain, runny nose, sore throat,
hoarseness, hemoptysis, wheezing.
dication.
incontinence.
-CNS: Headache, neck stiffness, visual disturbance, seizures.
Autoimmune / connective tissue disease : skin rash (sun responsive) dry red
eyes , dry mouth , hair loss , joint pain swelling

-Any chronic diseases? (mention the related diseases for the chief complaint)
-Previous hospitalization (Why?)
9-Past Surgical History (PSH) :

-Any previous operations? (Type, When, Complications, Outcome)
70 -Any blood transfusion?
HISTORY OF FEVER .. cont.

-Any drug that the patient is using?
-Allergies to food, drugs, dust.. etc.
11-Family History:
-Family history of similar symptoms
-Chronic diseases in the family.
-Genetic diseases.
-Cancer
12- Social History:
-Marital status, and if there are any children
-Educational Level
-Occupation
-Smoking: either passive or active (ask about type, duration, no. of packs per
day then calculate it in pack-year) or Ex-smoker (for how long?)
-Travelling & Immunization
- Sexual contact, Pets, Diet and Physical activity.
• Tuberculosis
Respiratory infection
• pneumonia
Localized GIT infection Abdominal abcess
Urinary tract infection ---
Infectious CNS infection ---
Sepsis ---
•Epstein-barr virus
Generalized • CMV
Viral Infection
Human immunode-
ficiency virus
• Lymphoma
• leukemia
Malignancies • Metastatic cancers
• Mesothelioma isn’t infection it pleural ma-
lignancy
• Rheumatoid arthritis
Non- Infectious Autoimmune • Rheumatoid fever
conditions • Inflammatory bowel disease
• Systemic lupus erythematosus
• Drug-Induced Fever (Captopril,Erythromy-
cin,Erythromyci).
Miscellaneous
• Heat stroke
• Dehydration
71
RESPIRATORY SYSTEM EXAMINATION
In any examination we start with : (WIPPPER )
• Wash your hand
• Introduce yourself
• Take permission
• Ensure the privacy
• Position the patient ( For Respiratory Examination The patient Should be
lying in bed with enough pillows to support him/her at 45 degrees, when ex-
amining the back the patient may sit over the edge of the bed )
Sitting up is preferred position since it allows examining front and back on
same time .
• Exposure ( All of the chest )
• make sure that you are standing on the Right side of the patient
General Appearance :
A : Appearance : well , ill , comatose
B : Body build : average , over weight , under weight
C : Color : cyanosed or Not
D : Distress or Deformities ( signs of distress: Flaring of the nose , Usage of
accessory muscle , Rapid Breathing , muscle fatigue , general weakness , low
blood pressure , fast pulse rate , mental confusion ).ability to speak full sen-
tence , audible stridor or wheeze .
E : Environment : look at the surrounding environment for sputum pots, neb-
ulizers, peak-flow meters, inhalers or oxygen mask .
F(V) : Vital signs = Pulse, RR, Temp, BP and O2 sat.
General Examination:
Hand:
Clubbing: increase in soft tissue deposition in the distal part of fingers or
toes.
Respiratory DD:
- Lung cancer
- Idiopathic pulmonary fibrosis
- Chronic pulmonary suppuration
- Bronchiectasis ( pus in airway )
- Lung abscess (pus in lung parynchema)
- Empyema (pus in pleural space )
72
1. Peripheral Cyanosis :
Cyanosis is a bluish or purplish tinge to the skin and mucous membranes it’s
caused by low oxygen levels in the red blood cells.( low tissue oxygen level)
Respiratory DD:
All causes of central cyanosis will cause peripheral cyanosis
any severe cardiac or pulmonary disease can cause hypoxemia ( low blood
oygen level) .. ( central cyanosis )
• exposure to cold
• pneumonia
• carbon monoxide poisoning
• emphysema
• pulmonary embolism
• chronic obstructive pulmonary disease (COPD)
• pulmonary edema
• fluid in the lungs
2. Muscle wasting :
Hand small muscles are thin hence it will be the early group of muscle to
show wasting before large muscles
Wasting can be general process ( malnutrition , chronic infection, autoim-
mune disorder) or from lung apex tumor invading brachial plexus
3.Nicotine staining : sign of cigarette smoking it is seen between the index
finger and middle finger.
Wrist :
1. Flapping tremor:
Ask the patient to dorsiflex the wrists with the arms outstretched and to
spread out the fingers. A flapping tremor with a 2 – 3 second cycle may occur
with severe CO2 retention, usually due to severe COPD.
73
2. Pulse:
•A bounding pulse may indicate CO2 retention. It’s a pulse that feels
as though your heart is pounding or racing (Watson’s water hammer
pulse). Technique: the examiner raises the patient’s arm vertically up-
wards The examiner grasps the muscular part of the patient’s forearm.
A water hammer pulse is felt as a tapping impulse which is transmitted
through the bulk of the muscles. Muscle wasting.
•Tachycardia and pulsus pardoxus are important sign of sever asthma.
Face :
1. Eyes:
- Pallor :
- Horner Syndrome:
Loss of sympathetic innervation
Constricted the pupil ( miosis) + partial ptosis and loss of sweating due
to (apical lung tumor (pancoast tumor) - compressing the sympathetic
chain in the neck).
- Jaundice :
Pallor Horner Syndrome - Jaundice
2. Nose:
- Flaring of the nose.
- Polyps: associated with asthma.
74
- Deviated nasal septum: due to nasal obstruction
- Engorged turbinates: due to various allergic

conditions.
3. Mouth:
- Color: zhecking for anemia or central cyanosis. Remember to ask them to
raise their tongue up and check underneath.
Blue lips : peripheral cyanosis
Blue tongue : central cyanosis
- Oral hygiene :
- Evidence of an upper respiratory tract infection: Pharyngeal redness + ton-

sillar enlargement:
4. cheek :
- Tenderness over the sinuses on palpation
(for sinusitis)
5. Ear:
- Tympanic membrane and discharge.
75
Neck:
• Lymph nodes: enlarged LN can be 2ry to chronic infection or malignan-
cy
- Occipital, Preauricular, Postauricular.
- Submental, Submandibular.
-Cervical: anterior, posterior, deep.
- Clavicular: supraclavicular, infraclavicular.
- Axillary.
Technique: use the pads of the index and middle finger to move the skin
in circular motions over the underlying tissues in each area; palpated
both sides of the neck simultaneously
RESPIRATORY SYSTEM EXAMINATION

(Local Examination in front)
The purpose of performing local respiratory examinations is to decide :

1) The disease is unilateral or bilateral
2) The disease falls in which pathology : consolidation , collapse , pneu-
mothorax or pleural effusion
76
- INSPECTION :
1. Shape of the chest
Pigeon chest Funnel chest Harrison’s sul- Barrel chest
(Pectus carinatum) (Pectus exacava- cus
tum)
Shape
a rounded, bulg-
linear depres- ing
a developmental sion of the chest with ab-
defect involving a lower ribs normal
an outward bowing
localized depres- just above the increase in the
Definition of the sternum and
sion costal margins anteroposterior
costal cartilages
of the lower end of at the site of diameter,
the sternum attachment of showing little
the diaphragm movement on
respiration
- Sever asthma
- Chronic childhood
in childhood
DDX respiratory illness - Marfan syndrome - COPD
- Rickets
- Rickets
Symmetry of the chest movement:

It should be examined from behind the patient looking down at the clavicles
during moderate respiration to notice any asymmetry in the expansion of the
upper lobes of the lung. Decreased movement on both or one side of the chest
is usually a sign of underlying pathology. Questionable yield ? how can we com-
pare both sides ? look over head
Comparing chest rise while patient lying or frontward movement while patient
is sitting suffice , the side with limited movement is the diseased side .
Causes of Decreased Chest Movement

UNILATERAL BILATERAL
- Pulmonary fibrosis
- Consolidation
- COPD
- Collapse
- Diffuse interstitial lung disease
- Pleural effusion
- Pneumothorax
Note: if there is paradoxical chest movement which is inward movement
of the chest with outward movement of the abdomen during inspiration
caused by diaphragmatic paralysis.
1. Skin rash.
2. Scars. 77
3. Usage of accessory muscle.
4. Subcutaneous emphysema:This is a sensation of crackles felt on pal-
pation, on inspection it may present as diffuse swelling of the chest
and neck. It may be caused by pneumothorax, pneumomediastinum or
esophageal rupture.
5.Prominent vain: in patient with Superior vena cava obstruction.
- PALPATION :
1.Trachea: for tracheal displacement or tracheal descent
From in front of the patient, try to palpate the trachea using the middle
finger, with the ring and index finger resting on sternal end of clavicles then
palpate with middle finger the space on either side of the trachea. Dis-
placement of the trachea is an important sign for diseases of the upper lobe
of the lung.
Causes of Tracheal Displacement

Towards the side of the lesion Away from the side of the lesion
Pulling effect Pushing effect
- Upper lobe collapse
- Massive pleural effusion
- Upper lobe fibrosis
- Tension pneumothorax
- Surgical removal
There may be other causes for tracheal displacement such as tumors

or a retrosternal goiter.
Tracheal Tug (Descent ): This means that the trachea moves inferiorly with
every inspiration.You don’t need to instruct the patient to breath deeply ,
it happen in normal individual with deep breathing .The abnormal finding is
feeling trachea moving downward with regular breathing.It is a sign of lung
hyperinflation & is seen with COPD patients.
2.Chest Expansion:
Place your hands firmly on the patient’s chest wall with your fingers extend-
ing around the sides of the chest( no restriction pressure applied just resting
hand on chest). Your thumbs should almost meet in the middle line. As the
patient takes a big breath in, your thumbs should move
symmetrically apart. At least 5 centimeters.
Site:
- Apex of the lung = Apical part.
- Upper zone = Above the nipple.
- Lower zone = Below the nipple.
78
3.Apex beat:it is the most lateral most inferior point where heart beat can
be flet.
Palpate the apex beat by the whole hand then by 3 fingers and
then by: 1finger (left 5th intercostal space 1cm medial to the
midclavicular line).
Causes of displacement:
Toward Away Not be palpable
collapse of lower plural effusion hyper expanded
zone of lung (pul- or tension pneu- secondary to
monary fibrosis). mothorax COPD.
4- Tactile Vocal Fremitus : it is a test of sound conductivity.Sound travel bet-

ter in solid media, gas, liquid
Palpate the chest wall either by the palm or the medial side of your
hand and ask the patient to say “99” . This repeated on the upper,
middle and lower areas moving from side to side (zigzag) on both the
front and the back. The idea of this exam depends on recognition of
vibration under examiner’s hand.
Normally it is felt the same bilaterally;

it may change as in it:
-Increases in areas with consolidation.
- Decreases in areas with pneumothorax and pleural effusion .
5.Ribs:
Gently compress the chest wall anteroposteriorly and laterally.
Localize tenderness suggests by:
- Rib fracture.
- Prolong coughing.
- Bone disease.
- Spontaneous as tumor deposition .
Tenderness over the costochondral junction suggests the diagnosis of cos-
tochondritis.
79
- PERCUSSION :
With left hand on the chest wall and the fingers separated and aligned-
between the ribs, the middle finger is pressed firmly against chest wall.
Then the middle finger of the right hand is used to strike firmly on the
middle phalanx and quickly removed so the note generated is not damp-
ened. The percussing hand should have a loose swinging movement from
the wrist NOT from elbow.The percussion should be done in a symmetri-
cal (zigzag) way to compare right and left.
Do not forget to percuss the supraclavicular fossa and direct percussion

on clavicles.
Site:
- On the apex.
- On the clavicle.
- On the chest.
- Both side of axilla.
The comment on the tone will be one of the followings:
Resonant Hyper-resonant Dull Stony dull:
- consolidation
Normal Lung pneumothorax pleural effusion
- lung collapse
- AUSCULTATION:
Using the diaphragm of the stethoscope, it is important to compare each
side with the other.
Remember to listen high up into the axillae and using the bell of the
stethoscope applied above the clavicles to listen to the lung apices.
1.Intensity of breath sounds
- May be equal or asymmetrical
- Reduction in intensity can be due to:
Unilateral Bilateral
- plural effusion
- pneumothorax - Emphysema
- large neoplasm - Thick chest wall
- pulmonary collapse
80
2.Quality of Breathing :
-Vesicular
Normal breath sounds are heard with the
stethoscope over nearly all parts of the chest.
- Long and loud inspiration.
- Short and soft expiration.
- No gap between them.
- Bronchial
Present when turbulence in the large airways are heard without being filtered
by the alveoli.
- Normally heard over the trachea.
- inspiration & Expiration are same in duration and intensity but more audible
in Expiration.
- There is gap between them.
Causes of bronchial breath sounds

Common Uncommon
- Lung consolidation - Localized pulmonary fibrosis
(lobar pneumonia) - Pleural effusion (above the
fluid)
- Collapsed lung (e.g. adjacent
to a pleural effusion)
3. Added Sounds :
Added sounds Wheezes Crackles Pleural friction rub
They are contin-
uous sounds that Interrupted non-musical
This is the sound of
have a musical sounds. low-pitched
Def. the pleural surfaces
quality which are crackles as râles and high
rubbing together
louder on expira- pitched ones as crepitation.
tion.
Early in-
Pan or Late inspi-
spiratory
ratory crackles
crackles
1.Fine crackles:
Interstitial lung
- Asthma disease
DDx 2.Medium crack- pleurisy
- COPD
les: Left ventric-
COPD
ular failure (pul-
monary edema)
3.Coarse crack-
les: Bronchiecta-
sis
Coarse crackles reflect large airways disease : (broncheactiasis)
Fine crackles reflect small airways disease : ( fibrosis , pulmonary edema )
81
How to differentiate between wheeze and stridor ?
Wheeze Stridor
Mostly Occurs during EXPIRATION ( but Occur during INSPIRATION
can be during inspiration or both )
Loudest over the chest Loudest over the trachea
4.Vocal Resonance : equivalent to TVF concept

- Whilst using the stethoscope, ask the patient to again say “99″ listen-
ing in all areas as with the Tactile vocal fremitus
- Over a consolidated lobe or lung the patient’s voice will become clear-
ly audible, while over a normal lung the sound is muffled.
(Local Examination from the back)

- INSPECTION :
1. Shape of the chest :
Kyphosis Scoliosis
Shape Kyphoscoliosis
is an exaggerated A combination of outward curva-

Definition forward curvature Lateral bowing ture (kyphosis) and lateral curva-
of the spine ture (scoliosis) of the spine.
- Congenital - Secondary to poliomyelitis
DDX - Osteoporosis
- Neuromuscular - Marfan’s syndrome
2. Scars :
- PALPATION
1.Chest Expansion:
2. Tactile Vocal Fremitus :

When feeling for tactile vocal fremitus the back, ask the patient to
wrap his/her arms around themselves to move the scapula from the
way.
82
3. Ribs .
- PERCUSSION:
When percussing the back, ask the patient to wrap his/her arms around
themselves to move the scapula from the way.
Diaphragmatic descent : compare dullness level during inspiration and
expiration .level should be lower with inspiration on both sides
- AUSCULTATION :
To complete my examination I should examine:
- Cardiac examination:
An essential part of the respiratory assessment
- The abdomen:
Palpate the liver descent due to emphysema, or for enlargement
from secondary deposits of tumor in cases of lung carcinoma.
- Legs:
Inspect the patient’s legs for swelling (oedema) or cyanosis, which
may be clues to cor pulmonale, and look for evidence of deep ve-
nous thrombosis.
- Pemberton Sign:
Ask the patient to lift the arms over the head and wait for 1min-
ute.note the development of facial plethora, cyanosis, inspiratory
stridor and non-pulsatile elevation of the jugular venous pressure.
This occurs in superior vena caval obstruction.
Reference ‘cough & hemoptysis ‘:

Writing Guideline for 33 ABC, Talley 7th Edition, 31 and 32 ABC,
Churchill’s Pocketbook of Differential Diagnosis 4th Edition.
Reference ‘ fever ‘ :
ABC book 31,32
http://www.aafp.org/afp/2003/1201/p2223.html
Reference ‘ examination’ :
ABC 31,32, Talley
83
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84 ....................................................................................
Endocrine Chapter
Hasan Sameer Tawakkul
Nizar Adnan Almaghrabi
Salman Gherman Alamri
revised by:
Suhaila Kamal Qari
86
History of Weight Gain
1-Personal Data :
Name, Age, Gender, Nationality, Route of Admission (Through OPD or ER?)

Weight gain and its duration (days/weeks/months/years)
3-History of Presenting Illness (HPI) :

Site :
Generalized, central (abdomen, face, and neck) or peripheral (lower
limbs).
Amount & Time Course :
How much weight have you gained (in kg)? In addition, in how long
period?
Rate :
Was it rapid or slow?
Progression :
Is it becoming worse, better or the same?
Eating Habits :
Have you been eating more?
Weight Loss Attempts :
Any attempts to lose weight? Were they successful?
Physical activity :
Have you been less active?
Impact on daily activities
Symptoms of Hypothyroidism: Appetite changes, change in bowel habits (con-
stipation), skin changes (dry, pale, scaly, coarse), hair loss, menorrhagia, fa-
tigue, loss of concentration, cold intolerance, hoarseness
Symptoms of Cushing’s: thin skin, easy bruising, proximal muscle weakness,
pink/violet stretch marks (striae) in the abdomen, irregular menses, hirsutism
Symptoms of Poly Cystic Ovarian Syndrome (PCOS) (if patient was female): Ol-
igomenorrhea or Amenorrhea, Hirsutism, Infertility
Complications of obesity: Symptoms of type 2 DM (polyuria, polydipsia, polyph-
agia), loss of libido, erectile dysfunction (males) + other symptoms like osteo-
arthritis or obstructive sleep apnea.
RAPID weight gain (days to weeks) - accumulation of excess fluid
- Edema
- CHF
- renal failure
- chronic liver disease
87
History of Weight Gain .. cont.
Exacerbation of primary weight gain
- Menopause
- Smoking cessation
- anything that impairs physical activity
5-Risk Factors :
Family/personal history of DM or hypothyroidism.
Use of steroid medications
Lack of Exercise & Physical inactivity
6-Constitutional Symptoms :
- Fever, Night sweats
- Are you feeling tired or unwell in addition to the weight gain?
- Are you feeling bloated or edematous? (Remember to look for edema on
examination.)
7-Systemic Review :
Most important systems are CVS, Rasp, CNS and GIT
8-Past Medical History (PMH) :

-Any previous history of similar symptoms?
-Any chronic diseases? (DM, HTN and ischemic heart disease)
-Previous radio-iodine treatment or radiotherapy?

-Any previous operations (surgery for goiter /thyroidectomy)? (Type, When,
Complications, Outcome)
10-Drug and Allergy
-Any drug that the patient is using? (E.g. steroids, oral contraceptive pills,
anti-thyroid drugs, insulin, anti-psychotics)
-Allergies to food, drugs, etc.
11-Family History :
-Chronic diseases in the family (DM, HTN, hypothyroidism and endocrine dis-
eases)
-Genetic diseases
-Cancer
12- Social History :

88 -Educational Level
History of Weight Gain .. cont.
-Occupation
-Diet
If related, ask about sexual contact, Pets
13- Differential Diagnosis of Weight Gain :

Endocrine Hypothyroidism:
• Symptoms: cold intolerance, constipation, irregular menses, excessive
sleepiness, lethargy, muscle aches.
• Signs: dry skin, thinning hair, puffy face, goiter, loss of eyebrow hair,
myxedema.
Cushing’s Syndrome:
• Symptoms: Irritability, amenorrhea, easily bruising.
• Signs: new or worsened HTN, glucose intolerance, hirsutism, buffalo
hump, thinning of skin, red striea.
Polycystic Ovarian Syndrome (PCOS):
• Symptoms: Irregular menses (oligomenorrhea), infertility.
• Signs: thinning hair, acne, and hirsutism.
Drugs-related • Corticosteroids
• Psychotropic medications
(e.g. lithium, SSRIs, antipsychotics)- & Anticonvulsants
• Oral contraceptive pills
• Diabetes medications (especially Insulin, followed by Sulfonylureas &
Thiazolidinedione)
89
History of Weight Loss
1-Personal Data :

Weight loss and its duration over months/years

- Intentional or Unintentional?
Was there was any intention (e.g. through exercise or diet) or other physio-
logical cause for weight loss or not?
- Amount & Time course
How much weight is lost over how much time?
-To be accurate, ensure that there is evidence of weight loss by asking
about:
1-Weight measurements from notes (if available)
2- Clothing or belt size changes
3-Impressions of friends and family on weight change
- Changes in appetite
Is it increasing, decrease or the same?
-Dietary History
Ask about:
1.Availability of food,
2.Use of nutritional (and herbal) supplements
3.Adequacy of the patient’s diet (amount of food consumed, balance of nu-
trients, etc.)
4.Daily caloric intake.
-Progression
•Are there any body image concerns or worries about eating?
•Any recent changes to social circumstance/lifestyle?
- General : Weakness, Fever, night sweats .
- Gastrointestinal: Dysphagia, Abdominal pain, Postprandial pain , Heart-
burn, Diarrhea , Bloody stools, Black/tarry stools, Oily/floating stool, Rectal
bleeding .
- Genitourinary: Hematuria, Lower urinary tract symptoms, Lower pelvic
pain .
- Neurologic: Headache, seizures, neuropathy
- Endocrinological: Fatigue, palpitations, anxiousness, and heat intolerance,
Polyuria, polydipsia and polyphagia .
90
History of Weight Loss .. cont.
- Cardio-respiratory : Hemoptysis, Cough, Dyspnea, Orthopnea, Paroxysmal
nocturnal dyspnea, Peripheral edema
- Psychiatric : Preoccupation with thinness
5-Risk Factors :
- Smoking/tobacco use
- Previous radiation exposure
- Previous chemotherapy
- Environmental exposures
- Infections
- Alcohol use
6-Constitutional Symptoms
Fever, Fatigue, Loss of appetite and Night sweating (you should already have
asked about them in the associated symptoms).
7-Systemic Review :
Must be complete, seeking symptoms in all major organ systems. (Ask about
symptoms you haven’t ask in the associated symptoms)

-Any chronic diseases? (DM. cancer, thyroid disease, autoimmune diseases,
liver & renal disease, psychiatric disorder)

-Any previous operations (e.g. gastric sleeve surgery)? (Type, When, Complica-
tions, Outcome) -Any blood transfusion?

-Any drug that the patient is using? (Antiretroviral drugs, cancer chemother-
apy drugs, digoxin, levodopa, metformin, NSAIDs, SSRIs, Withdrawal after
chronic high-dose psychotropic drugs)
-Allergies to food, drugs, dust... Etc.
11-Family History :
-Chronic diseases in the family (DM, thyroid disease, renal disease)
-Genetic diseases
-Cancer
12- Social History

-Marital status, and if there are any children 91
-Educational Level
-Occupation
-Smoking: either passive or active (ask about type, duration, no. of
packs per day then calculate it in pack-year) or Ex-smoker (for how
long?)
-Alcohol & Drug Abuse (amphetamines, cocaine, opioids)
13- Differential Diagnosis (DDx) of Weight Loss:

Diabetes Mellitus (DM)
- polyuria, polydipsia, infections,
- symptoms of type1; nausea, vomiting, anorexia (diabetic
ketoacidosis)
- Family history of DM
Hyperthyroidism
- Associated with palpitations, tremor, fatigue, weakness (may
Endocrinological
be subtle), heat intolerance, hair thinning/loss, anxiousness.
Adrenal Insufficiency
- History of metastases, tuberculosis, autoimmune endocrinop-
athies (primary adrenal insufficiency); glucocorticoid exposure
(tertiary adrenal insufficiency)
- Associated with fatigue, decreased appetite, weakness
Generally, many cancers can be associated with weight loss, in

addition to night sweats and loss of appetite
Important examples
Gastrointestinal Cancers
Pancreatic cancer: nausea, anorexia, abdominal bloating, up-
per abdominal pain/discomfort
Stomach cancer: Helicobacter pylori infection, prior gastric
ulcer, epigastric pain
Malignant
Colorectal cancer: rectal bleeding, change in bowel habits
Esophageal cancer: progressive dysphagia, painful swallowing
Non-Gastrointestinal Cancers
Non-Hodgkin’s lymphoma: night sweats, enlarged lymph nodes
Multiple myeloma: fatigue, bone pain, infections
Prostate cancer: obstructive urinary symptoms
Ovarian cancer: pelvic pain/pressure, abdominal bloating.
Breast cancer: Breast lump
Coeliac disease
- Diarrhea, bloating, abdominal pain/discomfort
Crohn’s disease
- Can occur in younger patients (15-40 years) and peaks again
in sixth decade,
Gastrointestinal - Abdominal pain, diarrhea (may be bloody), bloating
Ulcerative Colitis
- Can occur in younger patients (20-40 years) and peaks again
in sixth decade
- Abdominal pain, diarrhea (usually bloody), rectal bleeding,
92 arthritis
Depression
-Anhedonia, depressed mood, appetite changes, sleep
disturbance
Bulimia nervosa: recurrent episodes of binge eating and
Psychiatric compensatory behavior (e.g., purging, fasting, exercise),
concern about body image/weight
Anorexia nervosa
- Fear of gaining weight, food restriction, distorted body
image
Rheumatoid arthritis
Inflammatory/ Symmetric polyarthritis, joint pain/swelling
Rheumatologically Systemic lupus erythematosus
- Rash, fatigue, arthralgia/arthritis
HIV infection: History of injection drug use, unprotected
sex, needle stick injury, transfusions of blood
Infectious Tuberculosis (Pulmonary)
-immunosuppression, cough, night sweats, malaise, he-
moptysis
Parkinson’s disease
-Bradykinesia, cognitive impairment, resting tremor
Neurological Dementia
-Progressive cognitive dysfunction, memory loss, taste
changes
Cardiac cachexia syndrome
-Symptoms of advanced heart failure (e.g., dyspnea on
exertion, fatigue, orthopnea and paroxysmal nocturnal
Cardiovascular & dyspnea, peripheral edema)
Respiratory
Pulmonary cachexia syndrome
- Symptoms of advanced COPD or interstitial lung disease
(e.g., cough, dyspnea)
- Anticonvulsants (ex. topiramate, zonisamide),
- Antidepressants (e.g., selective serotonin-reuptake in-
hibitors, bupropion)
Drugs-Related - Diabetes medications (e.g., metformin; exenatide, lira-
glutide),
- Diuretics, laxatives
- Withdrawal after chronic high-dose psychotropic drugs
Inadequate nutrition
-Older age, poverty, inadequate resources, taste changes,
dental problems
Socially-related
Child or Elder Abuse (Neglect)
-Recurrent injuries, unstable home environment, inconsis-
tent/changing history, unexplained/inconsistent injuries
93
History of Polyuria
Introduce yourself. Take permission from the patient
1-Personal Data :
Name, Age, Gender, Nationality, Route of Admission (Through OPD or
ER?)

Passing excessive volumes of urine (polyuria), and its duration (minutes/
hours/days/months/years)

Onset :
Sudden or Gradual? (Also, ask about age at onset)
Quantity:
The quantity of urine passed per time large or small.
Frequency :
How many times would you pass urine per day? Is it now more than
usual?
Timing :
Is it transient or persistent?
- How many times would you pass urine per day?
- How many times would you pass urine at night?
Progression :
Exacerbating/Alleviating factors .
Fluid Intake :
How much fluid would you drink per day (e.g. in glasses or bottles)?
Is it now more than usual?
Color :
What is the color of the urine? (E.g. cloudy, clear or blood
stained)
Increased urinary frequency, Dysuria, Incontinence, Urgency, Hesitancy, Po-
lyphagia, Polydipsia, Weight loss, Hematuria and Nocturia
5-Risk Factors :
• Family history of diabetes insipidus or DM
• Head trauma or brain surgery Polyuria medically
• Obesity defined as a urine out-
put exceeding 3 L/day
•Smoking in adults and 2 L/m2 in
children; it should be dif-
6-Constitutional Symptoms : ferentiated from urinary
Fever, Fatigue, Loss of appetite and frequency or nocturia.
94 Night sweating.
History of Polyuria .. cont.
7-Systemic Review :
Should seek symptoms suggesting possible causes, including dry eyes and dry
mouth (Sjögren syndrome) and others.

-Any previous history of similar attack? History of psychiatric illness?
-Any chronic diseases? (Ask specifically about DM, HTN, chronic kidney disease
(CKD), sickle cell disease, cancer and hyperparathyroidism)
-Previous hospitalization (Why?) and recent IV fluid administration

-Any previous operations? (Type, when, complications, outcome) especially
brain surgery, and any history of head injury or brain trauma?
-History of urinary tract catheterization or obstruction?

-Any drug that the patient is using? (Especially The most common
diuretics, lithium, and nephrotoxic drugs) cause of polyuria in
-Allergies to food, drugs, dust... Etc. adults alone is taking
diuretics, while in both
11-Family History : children and adults the
-Family history of similar symptoms most common cause is
uncontrolled DM.
-Chronic diseases in the family? (DM or
diabetes insipidus)
-Genetic diseases
-Cancer

-Educational level
-Occupation
day
Then calculate it in pack-year) or Ex-smoker (for how long?)
-Caffeinated beverages, Alcohol & Drug Abuse
In addition, if related, ask about sexual contact, Pets, Diet and Physical Activ-
ity.
95
History of Polyuria ..cont.
13- Differential Diagnosis (DDx) of Polyuria :

- Diuretics (e.g. furosemide), lithium, excessive IV fluid
administration
Iatrogenic - Usually not iatrogenic, but alcohol and caffeine intake can
also cause polyuria
Diabetes Mellitus (DM)

- Associated with weight loss, recurrent infections (e.g
UTI), obesity, polydipsia and polyphagia
- Family history of DM (especially type 2)
Endocrine Central Diabetes Insipides (Central DI)
- Usually sudden onset
- Can be induced by head trauma, brain tumors and neuro-
surgery (especially pituitary surgery)
- Rarely familial
- Associated with polydipsia and nocturia
Psychogenic (or Primary) Polydipsia (PPD)
- Anxious, middle-aged women
Psychological
- Increased water intake
- History of psychiatric disorder
Hypercalcemia
- History of cancer or hyperparathyroidism
Metabolic
- Associated with confusion, fatigue, constipation and easy
fatigue
Nephrogenic Diabetes Insipidus (Nephrogenic DI)
- May be associated with sickle cell disease & Sjögren’s
syndrome
- Also associated with polydipsia and nocturia, but:
- In children:
- Almost always hereditary (+ve family history)
- Usually presents early in life
* In adults
- Almost always acquired with chronic lithium use and hy-
Renal and Urinary percalcemia
- Usually gradual onset
Chronic Kidney Disease (CKD)
- Associated with fatigue, edema, itching & nausea
- History of DM or hypertension
- Family history of CKD
Relief of urinary tract obstruction
Polyuria following urinary catheterization or obstructive
uropathy
96
Case History of Polyuria (In Patient with Diabetes Mellitus)
Personal History:
Ahmed Hussain Ali, a 45-year-old Saudi male admitted through ER.
- Chief Complaint :
Increased urination / 5 days.
- HPI:
The patient was well until 5 days back when he started to has gradual increas-
ing in urination, the patient notice that the amount and frequency of urine
increased with excessive thirst and much eating. He has infrequent attacks
of dizziness. There is no history of dysuria, urine retention, changing in urine
color or urethral discharge.
- Systemic Review: -ve
- Past medical & surgical History: -ve
- Drugs & Allergies: -ve .
- Family History: -ve apart from consanguinity & his father & mother have DM
- Social History: married and has 3 offsprings, teacher, good living conditions
& socio-economic status.
History Summary Example :

Ahmed is 45 y/o Saudi male with no known medical illness came through ER
complaining of increased urination for 5 days, associated with increased fre-
quency, increase thirst & eating. He has a positive family history of DM.
97
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98 ....................................................................................
Central Nervous System Chapter
Abdulaziz Abdullah Joharji
Shifaa Mansour Alsharif
Abrar Ghazi Najjar
Ohood Ayed Allogmani
Bushra Abed AL-harbi
Khawla Khaled Nafadi
revised by:
Suhaila Kamal Qari
100
Remember:
ORGANIZATION is the Key to Excellence.
Always Introduce Yourself and Take Permission.
101
History of Headache & Facial Pain
1. Personal data:
Name, Age, Gender, Nationality, Route of admission (Through ER or OPD).
2. Chief complaint + Its Duration
3. History of presenting illness:

Site: Generalized, Unilateral headache, Site of Pain if any.
Onset: When did it start, is it Sudden or Gradual?
Character: Ting the head “band like”, Throbbing pain.
Radiation of pain: May radiate to Jaw, Shoulder.
Alleviating factors: Sleeping or Pain Killers can relieve the pain.
Timing: Continuous or Intermittent? If Intermittent ask about Frequency?
Exacerbating factors: Aggravated by Sleep, Alcohol, Change in Position,
Cough, Sneezing and Stress.
Severity: How severe was the pain? (Affecting daily activity, Missing Work or
School).
Progression: Getting worse over time?
4. Associated symptoms:
Nausea, Vomiting, Tightness, Neck stiffness, Drowsiness, Loss of Conscious-
ness, Flashing, Lid swelling, Rash, Chills, Photophobia, Sonophobia, Lacrima-
tion, Rhinorrhea, Flushing, Irritability, Aura, Numbness, Confusion, Seizure,
Stuffy nose, Achy feeling in upper teeth, Ataxia, Disturbance of gait, Speech
or Vision disturbance, Double vision, Jaw Claudication.
5. Risk factors:
URTI, Sinusitis, Trauma, Tumor, Visual problems, Dental pain.
6. Constitutional symptoms:
Fever, Fatigue, Loss of appetite, Loss of weight, Night sweating.
7. Systemic review:
- CVS: Chest pain, Palpitations, Shortness of breath, Cough, Swollen legs or
feet.
- RS: SOB, Cough, Runny nose, Hemoptysis, Wheeze, Stridor, Chest Pain.
- GIT: Heartburn, Stomach pain, Jaundice, Increasing constipation, Persistent
Diarrhea, Blood in stools, Black stools.
- GUS: Frequency, Urgency, Dysuria, Hematuria, Nocturia, Incontinence.
- Hematological: Pallor, Jaundice, Bone pain, Bleeding from nose, Anemia,
Clots.
- Musculoskeletal: Numbness, Joint pain, Muscle weakness, Joint swelling.
- Reproductive (female): Irregular periods, Bleeding between periods, PMS.
102
History of Headache & Facial Pain .. cont.
8. Past Medical History:
- Similar condition, Recent infection, CRF, CLD, Chronic illness.
- Previous hospitalization (why?).
9. Past Surgical History:

- Any previous operations? (type, when, complication, outcome)
- Any Blood transfusions?
10. Drugs and allergy:

- Using any drugs? Having any Allergy to food, dust, drugs? Specifically ask
about Oral Contraceptive.
11. Family History:

- History of headache, Inherited disorders, Chronic diseases, Cancer.
12. Social History:

- Smoking / Alcohol / Drug abuse, Diet, Occupation, Education, Address, Mari-
tal Status, Children, Travelling, Immunization and Pets.
-Smoking: Duration, No. of packs per year, (Ex-Smoker: for how long?).
13- DDX.:
- Unilateral headache “however it can be bilateral”.
-Throbbing pain, Aggravated by intense physical activity.
Migraine
-Associated with Flashing, Photophobia and Nausea.
- Sometimes Preceded by Aura.
- Pain around one eye, which may become watery, red, with Lid Swell-
ing, Facial Flushing.
Cluster Head-
- Common in Smokers, Aggravated by Sleep and Alcohol.
ache
- Occur in cyclical patterns or clusters, Seasonal.
- Associated with Lacrimation and Rhinorrhea.
- Generalized Headache, “band like”.
Tension-Type
- Tightness in Frontal, Occipital and Temporal area.
Headache
- Not associated with Nausea, Vomiting, Weakness or Paresthesia.
- Worse in the morning, on Bending or Valsalva maneuver, and with
Coughing. Wakes the patient from sleeping.
Space Occupy- - Associated with Vomiting ± Nausea.
ing Lesion - Change in Mental Status ± Behavioral change.
- There may be Weakness, Ataxia or Disturbance of gait.
- Speech or Vision disturbance.
- Initially Localized then become Generalized.
- Sudden severe pain in the Occipital area “worst headache”
Subarachnoid - Associated with Neck stiffness, Decreased level of Consciousness,
Hemorrhage Numbness, Confusion.
- Often followed by: Vomiting, Collapse, Seizure and Coma.
- ± Convulsion.
103
History of Headache & Facial Pain .. cont.
- Pain, Pressure and Fullness in cheeks + Tenderness.

- Worse on Bending forward or Lie down.
Sinusitis Headache - Associated with Fever, Stuffy nose, Achy feeling in
upper teeth.
- Not associated with Nausea or Vomiting.
- Neck stiffness.
- Nausea, Vomiting.
Meningitis
- Fever, Decreased appetite.
- Irritability, Sleepiness and Photophobia.
- Double vision, Sudden permanent Loss of Vision.
- Fatigue, Weakness.
- Throbbing headache.
Temporal Arteritis
- Jaw pain, sometimes occur with chewing (Jaw Clau-
dication).
- Shoulder and Hip Pain and Stiffness.
Female gender is a
risk factor of Mi-
graine while Male
gender is a risk
factor of Cluster
Headache.
104
History of weakness
1-Personal data:
2. Chief complaint + Its Duration.

Site: (Generalized, Localized) (Asymmetric, Symmetric) (Proximal, Distal).
Onset: When did it start? (Abrupt, Subacute, Insidious).
Course: Worse at onset, Progressive, Episodic, Activity-dependent.
Alleviating Factors: Such as Exercise.
Exacerbating Factors: Such as Exercise.
Severity: How severe is the weakness? (How is patient carrying his daily ac-
tivity).
Visual disturbance, Sensory Loss, Speech changes, Tremor, Headache, Sei-
zure, Loss of Consciousness, Memory changes.
5. Risk factors:
Trauma, Tumor, Infection, DM, HTN, hyperlipidemia, cardiac diseases, previ-
ous TIA or stroke, Smoking.
7. Systemic review:
feet.
Clots.

• Similar condition, Recent infection, Chronic illness.
• Previous hospitalization (why?).
105
History of weakness .. cont.
- Any previous operations? (type, when, complication, outcome).
- Using any drugs? Having any Allergy to food, dust, drugs?
11. Family History:
- History of Weakness, Inherited disorders, Chronic diseases, Cancer.
12. Social History:
- Smoking / Alcohol / Drug abuse, Diet, Occupation, Education, Address,
Marital Status, Children, Travelling, Immunization and Pets.
- Smoking: Duration, No. of packs per year, (Ex-Smoker: for how long?).
How to Localize a Neurological Lesion:
- Contralateral Sensory/Motor deficits.
- Aphasia: Left Hemisphere Lesion.
Cerebral Cortex
- Visual-spatial deficits: Right Hemisphere Lesion.
- Hemiparesis: Primarily affects Face, Arms & Trunk.
- Subcortical areas: Internal Capsule, Cerebral Peduncles, Thala-
Subcortical Lesions mus and Pons.
- Hemiparesis Complete: Face, Arms and Legs.
- Incoordination.
Cerebellum - Intention Tremor.
- Ataxia.
- Cranial Nerves findings.
Brainstem - Crossed Hemiplegia: Deficits on Ipsilateral Face and Contralater-
al Body.
- Acute injury: Spinal Shock +UMNL Initially not present.
Spinal Cord
- UMNL: Spasticity, Hyperreflexia, Clonus, +ve Babinski sign.
13- DDx :
- Hemiplegia.
- Homonymous hemianopia.
Stroke - Hemianesthesia.
Upper - Dysphasia.
Motor - Loss of consciousness.
Neuron Compressive or Infiltra- - Signs and symptoms of increased ICP.
Lesion tive lesion - Unilateral or Bilateral sixth nerve palsy.
- Visual disturbance, Scanning Speech.
Multiple Sclerosis - Internuclear Ophthalmoplegia, Nystagmus.
- Intention tremor, Worsening with movements.
- Distal muscles, typically ascends, No wasting.
Guillain-Barre Syndrome - Reduced reflexes.
Lower - Recent Upper Respiratory or GIT infection.
Motor
Neuron Myasthenia gravis:
Lesion: - Muscular power decrease with use.
Neuromuscular Junction
- Ophthalmoparesis, Dysarthria, Bulbar and Respi-
106 ratory muscle involvement in severe cases.
History of Fits
1- Personal data:
-Name, Age, Gender, Nationality, Route of admission (Through ER or OPD).
3. History of presenting illness: (History from Patient and Witness)

Pre-ictal:
- When did it start, is it sudden or gradual?
- Warning, Strange smell or feeling of deja-vu (aura).
- Sweating, Weakness, Confusion, what pt. was doing?
- Provoking factors: Lack of Sleep, Stress, Recent Infection, Medication
use, History of alcohols intake, Compliance to treatment in known Epilep-
tic patients.
During attack:
- Altered consciousness, Loss of postural tone, Continence.
- Description of attack: Abnormal movements, Sensations, Strange Smell,
Visual hallucinations, Sudden loss of tone.
- Generalized tonic-clonic or Localized to one side of the body?
- Have you injured yourself? Passed urine during episode? Or Bite your
tongue?
- How many attacks? Time between attacks? Each attack for how long?
Post-ictal:
- Did you wake up feeling normal or drowsy, Headache? Weakness? Confu-
sion? Self-limited or needed help to recover?
- Headache, Neck stiffness, Nausea, Vomiting, Palpitation, Agitation, Diar-
rhea, Photophobia, Feel sleepy, Confusion, Irritability, Dysarthria.
5. Risk factors:
- Alcohol, Pregnancy, Head Trauma, Tumor, history of CNS infection, CNS In-
sult, Developmental history, Stroke, history of febrile seizure.
- Fever, Fatigue, Loss of appetite, Loss of weight, Night sweating.
7. Systemic review:
feet.
- GUS: Frequency, Urgency, Dysuria, Hematuria, Nocturia, Incontinence. 107
History of Fits .. cont.
- Hematological: Pallor, Jaundice, Bone pain, Bleeding from nose, Ane-
mia, Clots.

- Similar condition, Recent Infection, Cardiac Disease, Chronic illness, Psy-
chiatric History.


- Using any drugs? Having any allergy to food, dust, drugs?
- Anti-hypertensive, Antiepileptic, Antiarrhythmic.
11. Family History:

- History of Fits, Inherited disorders, Chronic diseases, Cancer.
12. Social History:

- Smoking / Alcohol / Drug abuse, Diet, Occupation, Education, Address,
Marital Status, Children, Travelling, Immunization and Pets.
- Smoking: Duration, No. of packs per year, (Ex-Smoker: for how long?)
NOTE :
- Aura: Sensation perceived by a patient that precedes a condition affecting
the brain. An aura often occurs before a migraine or seizure. It may consist
of flashing lights, a gleam of light, blurred vision, an odor, the feeling of a
breeze, numbness, weakness, or difficulty in speaking.
- Non-compliance to Antiepileptic drugs can cause Seizure.
- In Fits, you may take the information from the patient himself or from
someone saw him during the attack.
108
History of Fits .. cont.
13- DDX :
- Sudden feeling of Fear or Anxiousness.
- Aura, Hallucinations.
- Convulsions, Involuntary movements, Muscle
Seizure Rigidity.
- May Lose bladder control, tongue biting.
- Loss of consciousness and fall.
- Post-ictal may feel Confused and Fall asleep.
- Transient.
- Self-limited loss of consciousness with an inabil-
Syncope
ity to maintain postural tone.
- Spontaneous recovery (wake up feeling normal).
- Weakness or Paralysis typically in one side of
Transient ischemic attack (TIA) the body
- Pt. fall out without loss of consciousness.
Types of Seizure:
- Occur if you have epilepsy, which is condition that
Partial Seizures causes repeated seizures, happens only on one side of
the body.
- Occur on both sides of the body, include Grand Mal
Generalized seizures
(Tonic-Clonic) seizures and Petit Mal (Absence) seizures.
Major Causes of Seizure:

- Fever.
- Headache, Neck stiffness.
Meningitis
- Nausea, Vomiting, Photophobia,
- Feel sleepy, Confusion, Irritability.
- Headache.
- Unexplained Nausea or Vomiting.
Brain Tumor - Vision, Hearing, Speech problems.
- Gradual loss of Sensation or Movement in a limb.
- Partial localized to one side of the body.
- If there are at least two unprovoked epileptic seizures occur
Epilepsy
more 24 hours apart.
- Headache, usually anterior.
- Confusion, Visual disturbance, difficulty Speaking.
Hypertensive Enceph- - Muscle weakness in one side of the body.
alopathy - May present with Cardiovascular, Acute Renal Failure symp-
toms.
- HTN.
- HTN in pregnancy.
- Headache.
Eclampsia
- Nausea and Vomiting.
- Vision and Urinating problems.
- Headache, Sweating, Weakness, Confusion.
Hypoglycemia
- Hunger, Pale skin, Racing Pulse.
109
History of Tremors
1.Personal data:

Site.
Onset: When did it start, and is it Sudden or Gradual?
Character:
- Characteristics setting: At Rest, With Action, With Certain Posture.
- Description of tremor: Pill rolling, Course, Fine.
- Rate of tremor: Slow, Rapid.
Alleviating Factors: Reliving by: Alcohol use, Rest, Action.
Exacerbating factors:
- Aggravated by: e.g. β-agonist, Caffeine, Fear, Fatigue, Anxiety, Cold,
Intentional activities: such as drinking from a cup.
Severity: How severe is it? (Affecting on daily activity)
- Sweating, Weakness, Nervousness, Insomnia, Irritability, Hyperactivity,
Heat tolerance, Palpitation, Diarrhea, Severe pounding headache, Rigidity,
Dysphagia, Bradykinesia, Mask face, Ataxia, Nystagmus, Dysarthria, Head
tremor “nodding”, Vocal tremulousness, Resting tremor, Chorea.
5. Risk factors:
Alcohol, DM, Old age.
7. Systemic review:
feet.
- GIT: Heartburn, Jaundice, Increasing Constipation, Blood in stools, Black
stools.
Clots.
110 - Reproductive (female): Irregular periods, Bleeding between periods, PMS.
History of Tremors .. cont.
- Similar condition, Recent infection, Thyroid disease, Chronic illness.
-Using any drugs? Having any allergy to food, dust, drugs?
- Valproic acid, Lithium, Methylxanthines, Theophylline.
11. Family History:
- History of Tremors, Mental illness, Inherited disorders, Chronic diseases,
Cancer.
12. Social History:
- Smoking / Alcohol / Drug abuse, Diet, Occupation, Education, Address, Mari-
tal Status, Children, Travelling, Immunization and Pets.
- Smoking: Duration, No. of packs per year, (Ex-Smoker: for how long?).
13- DDx:
- Aggravated by β-agonist to treat asthma, Caffeine, Fear, Fatigue,
Physiologic
Anxiety.
tremor
- Rapid.
Shivering tremor - Aggravated by cold.
- With certain posture, e.g. arm outstretched or certain tasks e.g.
hand Writing.
Essential tremor - Exacerbated by intentional activities, such as drinking from a cup.
- Markedly decrease by alcohol use.
- Fine, Associated with head tremor “nodding”, Vocal tremulousness.
- With action “intention tremor”.
- Improved by rest.
Cerebellar tremor
- Has a course.
- Associated with Ataxia, Nystagmus, Dysarthria.
- At rest, Improved by action.
Parkinsonian
- Pill rolling, slow.
tremor
- Associated with Rigidity, Dysphagia, Bradykinesia, Mask face.
Hypoglycemia - Sweating. - Weakness. - Confusion.
- Nervousness, Insomnia, Irritability, Hyperactivity.
- Heat tolerance, Excessive sweating.
Hyperthyroidism
- Palpitation
- Diarrhea and Weight loss.
- Severe bounding Headache.
Pheochromocyto-
- Sweating.
ma
- Palpitation and Anxiety.
- Associated with resting Tremor, Rigidity, Bradykinesia, Chorea,
Wilson's disease Drooling.
- Symptoms and Signs of Liver Cirrhosis. 111
Example of an Epilepsy History
1.Personal data:
Ahmed, 26 Y/O Saudi, Male, Admitted Through ER on 2-1-1438 H.
2.Chief complaint + Its Duration:
Complaining of Abnormal Movement for 1 Day.
3.History of presenting illness:
The Patient Was on Usual Status till 1 Day Back, When He Started to Has
Abnormal Movements Which Were Abrupt in Onset, Appeared When He Was
Playing, The Condition Started by Abnormal Movement of the Right Limb for
2 Minutes Then Stiffening of All Body and Loss of Consciousness, Then Ton-
ic-Clonic Movement of All Limbs for 2 Minutes. Then He Slept for 45 Minutes
and Felt Pain in All Muscles.
4.Associated symptoms:
There Is No Loss of Memory, No Weakness & No Headache, Nor other Associ-
ated Symptoms.
5.Risk factors:
There is No risk factor regarding this case.
There is no Fever, Fatigue, Loss of appetite, Loss of weight, Night sweating.
7. Systemic review:
Not remarkable for any system.
- He Is Known Case of Epilepsy for 4 Years.
- Diagnosed at KFCH, Since He Was 4 Years, Controlled on Phenytoin.
- He has a History of 5 Previous Similar Attack with 2 Previous Admissions,
The Last Admission Was 6 Months ago.
- He hasn’t done any operation, Neither He received blood transfusion.
- He is using Phenytoin, Once a day, With a Good Compliance.
11. Family History:
- +Ve History of Epilepsy in His Father.
12. Social History:
- Nonsmoker, Single, Student, Good Living Conditions & Socio-Economic Sta-
tus, From Jeddah, has no pets.
Summary :
26 Y/O Saudi Male, Known Case of Epilepsy, Admitted Through ER Complain-
ing of Abnormal Movement for 1 Day. The Condition Started with Movement
of the Right Hand, Then Became Generalized Tonic-Clonic, for 2 Minutes
Then He Slept for 45 Minutes.
112
Examination of the Nervous System
Before Starting the Examination:
WIPPPER:
•Wash Your Hands.
•Introduce Yourself.
•Permission.
•Privacy.
•Position.
•Exposure.
•Right Side of the Patient.
Start the Examination by:

ABCDEV:
•Appearance: Looking Well, Ill or Comatose.
•Body Built: Cachectic, Underweight, Average, Overweight, Obese.
•Color: Normal, Cyanotic, Jaundiced, Pale.
•Deformity or Distress.
•Environment: Things Connected to the Patient (IV Line, Urinary
Catheter, Drain, O2 Mask, etc.) Wheelchair, Sputum Container, etc.
•Vital Signs: Blood Pressure, Pulse, Respiratory Rate, Temperature,
O2 Saturation “SpO2”.
CNS Examination Consists of:

1.General (High Cortical Function).
2.Cranial Nerves.
3.Motor System (Upper and Lower Limbs).
4.Coordination.
5.Sensory System (Upper and Lower Limbs).
113
High Cortical Function Examination
A.Handedness.
B.Consciousness.
C.Orientation.
D.Cognitive Function (Attention).
E.Memory.
F.Speech.
G.Meningeal Irritation.
- Handedness:
1- Shake hands.
2- Ask the patient if he is right- or left-handedness, to know his dominant hemisphere.
- Level of consciousness:
1-By Glasgow Coma Scale.
2- Best Response = 15.
3- Comatose Patient = 8 or less.
4- No Response (Deeply Unconscious/Dead) = 3.
Glasgow coma scale :

1 2 3 4 5 6
Opens eyes
Opens eyes Opens eyes
Does not in response
Eye in response sponta- --- ---
open eyes to painful
to voice neously
stimuli
Oriented
Incompre- Utters
Makes no Confused to time,
Verbal hensible inappropri- ---
sound disoriented place and
sounds ate words
person
Abnormal Flexion/
Extension Localizes
Makes no flexion to Withdrawal Obeys
Motor to painful painful
movement painful to painful command
stimuli stimuli
stimuli stimuli
- Orientation:
1- To time (E.g. Time of the day, Day of the week …).
2- To place (E.g. Name of the Hospital, City …).
3- To person (E.g. Name of the relative, Name of the doctor …).
** Disorientation can be Acute and reversible (Delirium), or Chronic and irreversible (De-
mentia).
** Mini-Mental State Examination is the Confirmatory Test.
- Attention:
1- Serial 7: Ask the patient to subtract 7 from 100, and keep subtracting 7. Normally a
person can complete it in 30 sec. with less than 4 errors.
2- Spelling Backward: Say a Five Letters Word, spell it and ask the patient to spell it
backward.
- Memory:
1- Remote (Long) Memory: Ask about patient’s birthdays, Name of schools attended. Sib-
ling Names.
114 2- Recent (Short) Memory: Ask about the event of the day E.g. what did you have for
breakfast, Laboratory test for today.
- Speech:
1- Ask the patient to read a short Surah from Quran as “Al-Ikhlas” and notice
for any abnormality.
2- Name 3 subjects.
3- Ask patient to repeat a sentence.
4- Ask patient to follow 1,2 and 3 step commands.
5- Ask the patient to read and write a sentence.
6- Dysarthria: Difficulty with Articulation of Words.
7- Dysphonia: Change in the voice quality.
8- Aphasia: Two Types:
A. Receptive aphasia is: Difficulty in Comprehension.
(Can’t understand spoken or written language).
B.Expressive aphasia is: Difficulty in Putting words together to give a
meaning.
(Can understand the spoken and written language but can’t answer).
- Meningeal irritation:
1- Kernig’s sign: Is positive when the hip and knee are flexed at 90 degrees.
And subsequent extension of the knee is painful to the lower back leading to
resistance.
2- Brudzinski’s sign: Is a clinical sign in which forced flexion of the neck elicits
a spontaneous reflex flexion of the hips. It is found in patients with Meningi-
tis, Subarachnoid Hemorrhage.
115
Cranial Nerves Examination
The First ( Olfactory ) Nerve
Action: Purely Sensory.
Functions: Smell.
Course:
Nerve Fibers arise in the mucous membrane of the nose and pass through the
cribriform plate of the ethmoid bone to synapse in the olfactory bulb. From
here the olfactory tract runs under the frontal lobe and terminates medial
temporal lobe on the same side.
- Examination:
1- Note the external appearance of the nose. Looking for Causes of bilateral anos-
rash or deformity. mia:
2- Examine the nasal vestibule by speculum looking for polyps -URTI (most common)
or nasal thickening. -Smoking.
3- Test each nostril separately with a series of bottles increasing age
containing essences of familiar and non-irritating smells, such -Basal skull fracture or
as coffee, vanilla. frontal fracture
- Ethmoid tumors
Anosmia (loss of the sense of smell): mostly Bilateral most
commonly due to upper respiratory tract infection. The main
Unilateral cause is head trauma without a fracture.
The second ( Optic ) Nerve

Action: Purely Sensory.
Course:
Million Fibers passing through the optic foramen close to the ophthalmic artery and join-
ing the nerve from the other side at the base of the brain to --- form the optic chiasm
leaving the chiasm --- optic tract --- to the lateral geniculate body --- fibers form the op-
tic radiation and pass through the posterior part of the internal capsule --- finishing in the
visual cortex of the occipital lobe
- Examination:
A) Visual Acuity:
- Is tested with the patient wearing his spectacles
using a Snellen’s chart, each eye is tested
separately, while the other is closed, requires the
patient to be 6 meters away from the chart.
-Normal visual acuity is (6/6 acuity) with distance
of 6 meters.
- If a patient who is unable to read even the
largest letter of the chart, should be asked to
count fingers held up in front of each eye, and
if this is not possible, then perception of hand
movement is tested. Failing this, a test for light
perception with a torch should be done.
116
- Any abnormality of the lens, cornea, fundus or optic nerve pathway can
cause reduction in visual acuity:
• Bilateral blindness of rapid onset: Include bilateral occipital lobe in-
farction, trauma.
• Sudden blindness in one eye can be due to retinal artery or vein occlu-
sion, temporal arteritis, optic neuropathy.
• Bilateral blindness of gradual onset: Caused by cataracts, acute glauco-
ma.
B) Visual Field:
Remove a patient’s spectacles, the examiner head should be at the same
level with the patient’s head, use a white- or red-tipped hat pin or pen, test
each eye separately.
Hold the pin at arm’s length.
It should be positioned halfway between the examiner and the patient, and
brought in from just outside your peripheral vision until the patient can see
it. Test all four quadrants.
Visual Field Pathway:

•Temporal side of right eye: Neural cells in
temporal side of the right eye carry sensation
from nasal field of right eye.
•Nasal side of right eye: Neural cells in nasal
side of the right eye carry sensation
from temporal field of right eye.
** The same in the left eye.
Visual Field Defect:

1- Bi-Temporal Hemianopia: Is due to a lesion
that affects the center of the optic chiasm,
damaging fibers from the nasal halves of the
retinas as they decussate.This will result in
a loss of both temporal halves of the visual
fields. Causes include a pituitary tumor.
2- Bi-Nasal Hemianopia: Is very rare and it is
due to bilaterallesions affecting the
uncrossed optic fibers.
3- Homonymous Hemianopia: Is due to a lesion
that damages the optic tract or radiation,
affecting the visual field on the right or left side.
For example, left temporal and right nasal field
loss will occur with a right-sided lesion.
4- Homonymous quadrantanopia: Is loss of the
upper or lower homonymous quadrants of the visual fields. This may be
due to temporal lobe lesions, which cause uppe quadrantanopia, or pari-
etal lobe lesions which cause lower quadrantanopia. 117
C)Color Discrimination:
Using Ishihara Chart, each eye is examined
separately.
- Lesion before optic Chiasma:
D) Light Reflex: Scotoma.
- Afferent Fiber (Sensory): Optic nerve II. - Chiasmal Lesion: Bi-Tem-
poral Homonymous Hemi-
- Efferent fiber (Motor): Oculomotor nerve III. anopia.
Technique: ** After chiasma:
- left track affects (RT Hom-
•With the patient opening both eyes, a torch- onymous Hemianopia).
light is brought from the lateral side of the eye -Right track affects (LT Hom-
and moved medially. onymous Hemianopia).
Normal finding: Constriction of the pupil in the same eye (direct response)
and the other eye (consensual response).
•Move the torch in arc from pupil to pupil.
Normally, both pupils should constrict when light is shown in either eye.
“Marcus Gunn pupillary sign” for Afferent Pupillary Defect:
If an eye has an optic nerve abnormality or severely reduced acuity, the af-
fected eye will have its’ pupil dilate paradoxically when the torch is moved
from the normal eye to it. This means that the pupil will constrict “consensu-
ally” when light is put in the normal eye but it will dilate when light is di-
rected at it because of its’ optic nerve (afferent) is not functioning properly.
E) Accommodation:
- Afferent Fiber (Sensory): Optic nerve II.
- Efferent fiber (Motor): Oculomotor nerve III.
Technique:
Ask the patient to look at the wall in front of him and then bring a pen or
any object 30 cm in front of the nose. Normal response:
i.Miosis (constriction of both pupils).
ii.Convergence of the eyes.
iii.Accommodation (increased convexity of the two lenses).
F) Fundoscopy:
Assess the retina and the optic nerves.
The Third (Oculomotor), Fourth (Trochlear) and Sixth (Abducens) Nerves

Anatomy:
- 3rd Nerve Course:
118
Arise from midbrain, its nucleus is located ventral to cerebral aqueduct in
periaqueductal gray matter, its fibers pass beside the red nucleus and cortico-
spinal pyramidal track – pass between posterior cerebral artery and superior
cerebellar artery beside basilar artery – it enters the orbit through superior
orbital fissure – divided to sup. Branch (supply sup. rectus) and inf. branch
(supply inf. rectus).
- 4th Nerve Course:
Arises from the Trochlear Nucleus of the brain- emerging from the posterior
aspect of the midbrain (it is the only cranial nerve that exit from the poste-
rior midbrain) It runs anteriorly and inferiorly within the subarachnoid space
before piercing the dura mater adjacent to the posterior clinoid process of
the sphenoid bone- it moves along the lateral wall of the cavernous sinus -
entering the orbit of the eye via the superior orbital fissure.
- 6th Nerve Course:
The abducens nerve arises from the abducens nucleus in the pons of the
brain- exits the brainstem at the junction of the pons and the medulla- enters
the subarachnoid space and pierces the dura mater to run in a space known
as Dorello’s canal- travels through the cavernous sinus at the tip of the pe-
trous temporal bone- entering the orbit of the eye through the superior orbit-
al fissure. 119
Muscles of the Eye and their Functions:
Extraocular muscles which are responsible for the movement of the eye:
Muscle Nerve supply Action

Medial rectus III CN Adduction.
Lateral rectus VI CN Abduction.
Superior rectus III CN Bring the eye up and laterally.
Inferior rectus III CN Bring the eye down and laterally.
Superior oblique IV CN Bring the eye down and medially.
Inferior oblique III CN Bring the eye up and medially.
There are two Intraocular muscles, which are the muscles that constrict and
dilate the pupil:
Muscle Nerve supply Action
Parasympathetic fibers running
Constrictor pupillary m. Miosis.
with the III CN.
Dilator pupillary m. Sympathetic nerve fibers. Mydriasis.
Muscles of the eyelids, which are the muscles that open and close the eye:
A)Opening: By
•Levator Palpebrae Superiors Muscle, supplied by III CN.
•Muller muscle, supplied by sympathetic nerves.
B)Closing: By
Orbicularis Oculi Muscle supplied by VII (Facial) CN.
Examination:
-Inspection:
Eye: Look for size, shape, diplopia, squint, nystagmus.
Eyelid: Look for ptosis.
-Eye Movement:
Technique:
Patient must open both eyes and follow the movement of the examiner’s
finger. The examiner should move his finger in the form of an H shape, to
check all the directions of muscles movement.
Look for any restriction of movement, Diplopia, Nystagmus or Eye Pain.
-Reflexes:
Light reflex and accommodation reflex as discussed in optic nerve.
Diseases:
Third Nerve Lesion:
Causes:
•Central causes include: Vascular lesions in the
brainstem, Tumors and rarely, Demyelination.
•Peripheral causes include: Aneurysm.
120
Features:
1. Complete Ptosis: Due to loss of Levator Palpebrae Superiors Muscle.
2. Dilated Pupil, Unreactive to light: Loss of constrictor pupillary muscle inner-
vation from the parasympathetic fibers that accompany the 3rd CN.
3. Loss of Accommodation reflex, no Miosis.
4. Divergent Strabismus: Dominance of the intact lateral rectus muscle and
superior oblique muscle will pull the eye down and out.
5. Diplopia (Double Vision).
Fourth Nerve Lesion:
Feature:
-The lesion results in paralysis of the superior
oblique muscle so the eye will look inwards
with weakness of downward movement and
the patient will experience diplopia.
-The patient let his head tilted away from the
lesion—the opposite shoulder (this allows the
patient to maintain binocular vision).
Sixth Nerve Lesion:

Cause:
•Bilateral lesions: Trauma or Wernicke’s
encephalopathy.
•Unilateral lesion: Sixth nerve lesions are most
commonly idiopathic or related to trauma.
Feature:
1. Convergent strabismus.
2. Restriction of lateral movement.
3. Diplopia.
The Fifth (Trigeminal) Nerve
Action: Sensory & Motor.

Function: Sensation over the face, Muscles of
Mastication.
course:
A- Nuclei:
-Motor and touch sensory nucleus found in the pons.
-Proprioceptive nucleus lies in the midbrain.
-Pain and temperature sensory nucleus lies in the medulla oblongata.
121
Nerve Course:
From pons through the cerebellopontine angle , temporal lobe , the
nerve forms the trigeminal ganglion at the petrous part of temporal
bone, from the ganglion arise the three sensory divisions:
1-The ophthalmic nerve (v1).
2-The maxillary nerve (v2).
3-The mandibular nerve (v3).
The motor fibers run with the mandibular branch
and supply the chewing muscles (temporalis,
masseter, and medial & lateral pterygoid muscles).
Examination:
Sensory:
1-Ask patient to close his eyes.
2-Test all the three division and compare both side for pain sensation, light
touch and temperature (not routinely), by using a sharp end of neurological
pine for pain sensation, cotton for light touch.
3-Ask the patient whether it feels sharp or light sensation and localize it.
Motor:
1- Inspect for wasting of temporal and masseter
muscles.
2- Ask patient to clench the teeth and palpate
to Check for contraction of the masseter muscles.
3- Ask patient to bite forcefully on a wooden
Tongue depressor and try to pull it out to Measure
the strength of the muscles.
4- Ask patient to open his mouth while you Try to
force closing, this will test the strength of the pterygoid muscles.
Reflexes:
1- Corneal reflex:
Afferent: Trigeminal Nerve (Ophthalmic Division).
Efferent: Facial Nerve.
Technique: Touch the lateral part of the cornea by a A unilateral lesion
cotton wool. of the motor divi-
Normal response: Blinking of both eyes (direct & sion will cause the
jaw deviate to the
consensual).Abnormal response:
same side (weak) of
-Unilateral ophthalmic palsy will cause no reflex at all. the lesion.
-Unilateral facial nerve palsy will cause contralateral
blinking.
2- Jaw jerk (Masseter Reflex):

Technique: Ask the patient to open his mouth
slightly, place your index on the tip of the jaw
and tapped lightly with hammer.
Normal response: Slight closure of the mouth or
no reaction at all.
Abnormal response: In UMNL above the pons,
there will be an exaggerated jaw reflex.
122
The Seventh (Facial) Nerve
Action: Motor & Sensory
Function: Muscles of Facial Expression, Stapedius Muscles, Taste Sensation
to anterior 2/3 of the tongue.
COURSE:
The facial nerve’s nucleus present in the pons, leaves the pons through
the cerebellopontine , enter the middle ear through the facial canal, to
geniculate ganglion, and leaves the skull through the stylomastoid
foramen , to the middle of the parotid gland & gives its branches to supply
the muscles of facial expression (frontalis, orbicularis oculi, buccinators, or-
bucalrisoris).
Examination: The upper part of the

Inspection: face receives bilateral
-Look for facial asymmetry. innervation; while the
lower part of the face
-Smoothing of forehead wrinkles. receives a unilateral in-
-Angle of the eye. nervation only from the
contralateral cerebral
-Smoothing of nasolabial folds. hemisphere.
-Drooping of the corner of the mouth.
-Drooping of saliva.
Sensory:
Test for taste sensation in anterior 2/3 of the tongue by asking the
patient to protrude his tongue and placing sugar, salt, sweet, bitter
substance on each side of the tongue, the mouth is rinsed with water
between each sample.
Motor:
-Frontalis Muscle: Ask the patient to raise his eyebrows while you try
to push downward, ask him to resist your movement then assess the
power of the muscle.
-Orbicularis Oculi: Ask the patient to close his eyes tightly while you
try to open them.
-Buccinators Muscle: Ask the patient to close his mouth, to fill it with
air and try to deflate it with your hands pressing against cheek.
-Orbicularis Oris: Ask the patient to whistle and smile.
If a lower motor neuron

lesion is detected, check
quickly the ear and pal-
atal vesicles for herpes
zoster of the geniculate
ganglion (the Ramsay
Hunt syndrome).
123
- Corneal reflex: As discussed previously (see trigeminal nerve).
Diseases: UMNL VS LMNL of the facial nerve:
Upper Motor Neuron Lesions (UMNL) Lower Motor Neuron Lesions (LMNL)
Caused by any insult below the facial nerve
nucleus or the facial nerve peripherally.
Caused by any insult above the facial nerve
Most Common causes include: Bell’s palsy,
nucleus.
HZN infection inside the ear (Ramsay Hunt
Common cause is a stroke.
Syndrome) and Guillain-Barre syndrome (Bi-
lateral Facial Weakness).
Contralateral paralysis of facial expression Ipsilateral paralysis of facial expression mus-
muscles only in the lower part of the face. cles in the whole side of the face.
Remember!!
Upper SAVE Upper.
The Eighth ( Acoustic ) Nerve

Function:
The Eighth (Acoustic) Nerve has two components:
•The Cochlear responsible for hearing.
•The Vestibular responsible balance.
Course:
Fibers for hearing originate in the organ of Corti and run to the cochlear nuclei
in the pons.
Examination:
A) Remove hearing aid if a patient wears it.
B) Examine the pinna and look for scars behind the ears. Pull on the pinna gen-
tly (it is tender).
124
C) Feel for nodes (pre- and post-auricular) that may indicate disease of the
external auditory meatus.
D) Inspect the eardrum by pull up and backward on the auricle before insert-
ing the otoscope.
The Normal Eardrum (Tympanic Membrane) is pearly gray and concave.
E) Look for Wax, Perforation and Inflammation.
Rinne Test: A 512 or 256 Hz vibrating tuning fork is placed on the mastoid
process, behind the ear.
-Normally: The Note is audible at the external meatus.
-If the patient has nerve deafness: The Note is audible at the external
meatus, as air and bone conduction are reduced equally, so that air con-
duction is better (as is normal). This is termed Rinne-positive.
- If there is a conduction (Middle Ear) deafness: No Note is audible at the
external meatus. This is termed Rinne-negative.
Weber Test: A vibrating 256 or 512 Hz tuning fork is positioned on the center
of the forehead.
- Normally the sound is heard in the center of the forehead.
- If there is nerve deafness: Causes the sound to be heard better in the
normal ear. A patient with a conduction deafness finds the sound louder
in the abnormal ear.
The Ninth (Glossopharyngeal) & Tenth (Vagus) Nerves

Action:
•Glossopharyngeal: Motor, Sensory, Secretory.
•Vagus: Motor, Sensory.
Function:
- Glossopharyngeal: Sensation pharynx, middle and inner ear, posterior
1/3 of the tongue (taste & general sensation), secretory fibers to parot-
id. Motor fibers to stylopharyngeus.
- Vagus: Sensation pharynx, larynx and innervates muscles of the phar-
125
ynx, larynx & the palate.
Course:
•Both have nuclei in the medulla multiple nerve fibers exit the medul-
la and join to form the 9th & 10th cranial nerves they exit the skull
through the jugular foramen.
Examination:
Inspection:
A-Ask the patient to speak; to assess hoarseness (which may occur
with a unilateral recurrent laryngeal nerve lesion), which is a branch
from the Vagus nerve.
B- Ask the patient to cough & listen for the characteristic bovine
cough that occurs with recurrent laryngeal nerve lesions.
C- Ask the patient to open his mouth and inspect the palate with a
torch. Check any displacement of the uvula. Then ask the patient to
say ‘ah!’ and observe the movement of the uvula, normally the uvula
should be in the middle.
D-Ask the patient to swallow a small amount of water and watch for
regurgitation into the nose, or coughing.
*If the uvula is deviate

to one side this indicates
a unilateral tenth nerve
palsy.
*The uvula will deviate
- Gag Reflex: to the opposite (normal)
Afferent: Glossopharyngeal. side.
Efferent: Vagus.
Technique:
Touch the back of the pharynx (posterior 1/3 of
the tongue) with a spatula, then ask the patient Most common
if he can feel the touch of the spatula or not, cause of a re-
this will assess (Glossopharyngeal). duced gag reflex
Normal response: There is reflex, contraction of the soft is old age.
palate (Vagus).
Abnormal response: If the patient felt the touch but no
gag reflex, this suggests a tenth nerve palsy.
126
The Eleventh (Accessory) Nerve
Action: Motor.
Function: This nerve supplies both the Trapezius and Sternocleidomastoid
muscles.
Course: This nerve has two origins:
•Central portion: Which arise in the medulla oblongata.
•Spinal portion: Which arise from the upper five cervical segments of the
spinal cord.
The nerve leaves the skull through the jugular foramen with 9th and 10th Cra-
nial Nerves to supply Trapezius and Sternocleidomastoid muscles.
Examination:
- Examination of the trapezius muscle:
Ask the patient to shrug his shoulders while you try
to push them down & feel the bulk of the muscle.
Examination of the sternocleidomastoid muscles:

Ask the patient to turn the head against your
resistance and check the bulk of the muscle.
The Twelfth (Hypoglossal) Nerve

Action: Motor.
Course: Arises from the medulla. It leaves the skull via the hypoglossal fora-
men.
Examination:
Inspection:
Look for Wasting, Fasciculation (Fine, Irregular, Non-Rhythmical Muscle
Fiber Contractions).
Motor:
Ask the patient to stick out the tongue if it is deviated (towards the
weaker (affected)) this indicate a unilateral lower motor neuron lesion.
Trigeminal nerve The jaw will deviate to the same (affected) side of the lesion.
Vagus nerve The uvula will deviate to the opposite (normal) side.
Hypoglossal nerve The Tongue will deviate to the same (affected) side of the lesion.
UMNL: Paralysis of muscles of the opposite side (lower part only)
Facial nerve
LMNL: Paralysis of muscles of the same side
127
Upper Limbs Examinations
Motor System
Start by exposing both upper limbs and sit the patient over the edge of the
bed.
The motor system includes the assessment of the following:
- Inspection (Skin – Muscle – Bone).
- Palpation: Tone - Power.
- Percussion (Reflexes).
1-Inspection: (Skin – Muscle – Bone) Look for:

A)Skin lesions:
Scars, Rash, Neuro-Cutaneous Legions, Hair Distribution.
B)Muscle:
i.Muscle Bulk:
Notice the presence of atrophy or hypertrophy and whether it is generalized/
localized, proximal /distal and symmetrical/ asymmetrical.
Atrophy of muscles:
Implies lower motor neuron lesions, muscle disease or prolong immobilization.
Hypertrophy:
Muscular dystrophy as in Duchene Muscular Dystrophy.
ii.Involuntary Movement:
- Chorea: Rapid, Jerky dancing movement aggravated by emotional stress and
activity, Disappears during sleep.
- Athetosis: Slow, Continuous writing movement of the extremities and face,
aggravated by voluntary activity and emotional stress.
- Tremors: Rhythmical alternating movement they may occur at rest or at ac-
tion.
- Fasciculation: Rapid involuntary Contraction of one or more muscle fibers,
best seen in the tongue and thinner eminence because there is minimal subcu-
taneous fat.
C)Bone: Abnormal Posture.
2-Muscle tone:
The tone is: The resistance in the muscles to passive movement.
Technique:
- Ask the patient to relax.
- Support his hand with your hand and use the other hand to do
the test.
- Shake test: Shake the hand of the patient and then
rotate the hand around the joint in circular way to assess
the tone. Proximal wasting
- Resistance to passive stretch around the joints: indicates myopa-
• Wrist – Flexion/Extension. thy. Except myo-
• Elbow - Flexion/Extension. tonic dystrophy
• Shoulder- Flexion/Extension, Abduction/ Adduction. which is distal.
128
Findings :
1- Normal tone.
2- Hypotonia: Decreases in muscle tone. Distal wasting in-
3- Hypertonia: Increases in muscle tone. dicates peripheral
neuropathy Except
spinal muscular
atrophy which is
proximal.
There are two types of hypertonia, spasticity and rigidity:
SPASTICITY RIGIDITY
Increase of resistance of the muscle to passive Increase of resistance of the muscle to passive
movement with maximum resistant at the begin- movement which is uniform throughout the
ning of movement. range of movement which is either smooth (lead
Velocity dependent pipe) or intermittent (cog wheel).
- Due to pyramidal lesion (UMNL). - Due to extrapyramidal lesion.
- Increased reflexes. - Normal reflexes.
- Does not change with position or emotional - Does not change with position or emotional
stress. stress.
3-muscle power :
It’s the active movement of the muscles around the joints.
Technique:
Start with pronator drift (ask patient to raise both arms up then close his
eyes. If there is a pyramidal weakness the affected limb will pronate and
drift downward), Then ask the patient to try to raise each arm above the
plain i.e. against gravity, if he could do it, that means his power is three or
above. If not, his power is less than 3.
If he has a power of 3 or more, start to check for
his muscle power while you are applying a resistance
to the movements, you ask him to do as follows:
A) In Shoulder Joint:
- Abduction with elbow flexed (C5, C6). shoulder abduction
- Adduction with elbow flexed (C6, C7, C8).
B) In Elbow Joint:
- Flexion (C5, C6).
- Extension (C7, C8).
elbow flexion
C) In wrist joint:
- Flexion “make a fist and bend hand”(C6, C7).
- Extension “make a fist and extend hand”(C7, C8).
D) In Fingers:
Extension, Flexion, Adduction and Wrist extension
Abduction. 129
Finding:
Graded from 0 to 5 by the MRC grading scale as the following:
0 No contraction.
1 Flicker of contraction.
2 Active movements with gravity eliminated.
3 Active movements against gravity.
4 Movements against moderate resistance.
5 Normal power (Movement against full resistance).
4- Reflexes:
-Hold the hammer by the end of the handle, so be a swinger not a stubber
when striking a tendon.
130
Coordination
Poor Visual acuity, Cerebellar Disorders and Sensory loss affect coordination.
i. Finger – nose test:
• Ask the patient to touch his nose with the index finger and then turn the
finger around and touch your outstretched forefinger at nearly for extension
of the shoulder and elbow.
• Intention tremors and/or overshooting

indicate Cerebellar Disorder.
ii .Rapid Alternating Movement:

• Ask the patient to pronate and supinate his
hand on the dorsum of the other hand as
rapidly as possible.
• Dysdiadochokinesia: Is the inability to perform it.
iii.Rebound:
• Ask the patient to lift the arms rapidly from the side to 90 degrees in front
and stop.
• Cerebellar lesion: Hypotonia due to a
cerebellar lesion causes delay in stopping the
arm.
131
Sensory System
- Test each dermatome separately.
- Start by deep sensation first.
- Start with the area you think is
affected then go to the normal
areas.
•Deep sensation :
1-Proprioception (joint position):
Hold the middle phalanx of the
patient index finger by side
then flex and extend the distal
phalanx telling the patient
which direction you mean by
up and down then repeat it
with his eyes closed.
2-Vibration sense: By using a
tuning fork (128 Hz).
•Superficial Sensation:
Equipment: Cotton ball, Safety pin,
Tubes with warm and cold water.
1- Light touch: Use the cotton and
touch the skin lightly then ask the patient to say yes when he can feel it
while closing his eyes, examine all dermatomes.
2- Pain sensation: The same idea, but with the tip of a pin in all der-
matomes.
3-Temperature: By using the two tubes of cold and warm water in all der-
matomes.
•Cortical Sensation:
1-Two points discrimination: Ability to identify 2 points simultaneously
to the dorsum of the foot or pulp of the finger. Approximate the 2 points
together until he preconceives them as one point.
2-Tactile Localization: Ability to localize the point of touch with closed
eyes.
To complete my examination:
-Check for Skin; Neurofibromatosis, Cutaneous Angiomata or Herpes Zoster.
-Look for Back deformity or Scar.
-Palpate for Tenderness over the Vertebral Bodies.
-Auscultate for Bruit.
132
Lower limb examination
Motor System
Start by exposing both lower limbs and sit the patient over the edge of the
bed.
The motor system includes the assessment of the following:
• Inspection (Skin – Muscle – Bone).
• Palpation: Tone - Power.
Inspection: (Skin – Muscle – Bone).

As in upper limb (see above).
2-Muscle tone:
The patient’s leg must be supported above the examined joint and completely
relaxed.
Technique:
Shake test:
Shake the feet of the patient and then rotate the feet around the ankle joint
in circular way to assess the tone.
- Resistance to passive stretch around the joints:
• Ankle – Dorsiflexion, Planter flexion, Inversion, Eversion.
• Knee - Flexion, Extension.
• Hip – Flexion, Extension, Abduction, Adduction, medial and lateral rotation.
Findings:
- Normal tone.
- Hypotonia: Decreases in muscle tone. Inability of the pa-
- Hypertonia: Increases in muscle tone. tient to stand from
sitting position
3- muscle power: (on chair) indicate
proximal muscle
Technique:
weakness .
First ask the patient lift both legs above the plain i.e. against gravity:
a) The Hip Joint:
• Flexion (L2, L3): Ask the patient to lift the leg straight and not let you
push it down (having placed your hand above the knee).
• Extension (L5, S1, S2): Ask the patient to keep the leg down and not let
you pull it up from underneath the calf or ankle.
• Adduction (L2, L3, L4): Ask the patient to keep the leg adducted and
not let you push it out.
• Abduction (L4, L5, L6): Ask the patient to abduct the leg and not let
you push it in.
B)The Knee Joint:
• Flexion (L5, S1): Ask the patient to bend the knee and not let you
straighten it.
133
• Extension (L3, L4): With the knee slightly bent, ask the patient to
straighten the knee and not let you bend it.
C)The Ankle Joint:
• Plantar Flexion (S1, S2): Ask the patient to push the foot down and
not let you push it up.
• Dorsiflexion (L4, L5): Ask the patient to bring the foot up and not
let you bend it.
knee flexion Hip abduction
Ankle planter flexion Hip flexion
4- Reflexes :
• Deep Reflexes:
Technique:
The leg that is being examined must be relaxed on the side of the bed or sup-
ported by the examiner’s left hand.
A)Knee Jerk (L2, L3, L4):
Slide one arm under the patient’s knee so that they are slightly bent
and supported. The tendon hammer is to fall onto the infrapatellar
tendon.
• Normal response: Extension of the knee with contraction of the quadriceps
muscle.
B) Ankle jerk (S1, S2):
Have the foot in the mid-position at the ankle
with the knee bent, the thigh externally
rotated on the bed and the foot held in
dorsiflexion by you. Allow the hammer to fall
on the Achilles tendon.
• Normal response: Plantar flexion of the foot with
contraction of the Gastrocnemius muscle.
134
- Characteristics of pathological hyperreflexia (+4):
Clonus:
It’s a rhythmic series of involuntary muscular contraction evoked by a sudden
sustained stretching of the tendon. Presence of clones indicates Pyramidal
tract lesion i.e. (UMNL).
A)Ankle clonus: Keep the patient in supine position. Hold the relaxed low-
er leg in your hand, and sharply dorsiflex the foot and hold it dorsiflexed.
Positive response: The foot goes trough planter flexion and dorsiflexion
movements repeatedly > 3 beats.
N.B Up to 10 beats of ankle clonus may be normal in the first 2 months of life.
Normally, nothing is felt.
B)Patellar clonus: Keep the patient in a supine position, then hold the
superior border of the patella and give a quick sustained push toward the
foot.
Positive response: The patella moves up
and down repeatedly.
Normally, Nothing Happens.
• Superficial Reflex:
Plantar reflex (L4, S1):
By using a blunt object like a key, stroke up the lateral aspect of the sole, and
carry the stimulus over the base of the metatarsals ending near the ball of the
great toe.
- Normal response: Plantar flexion of the big toe with Flexion of other toes.
-Abnormal response: Dorsiflexion of the big toe (Positive Babinski Sign).
N.B Positive Babinski sign considered normal response in infants until 6 month
of life.
135
Summary of the deep tendon reflexes
Deep tendon reflex Muscle involved Nerve supply Root supply
Biceps Biceps m. Musculocutaneous C5, C6
Triceps Triceps m. Radial C6, C7, C8
Brachioradialis Brachioradialis m. Radial C5, C6
Knee Quadriceps femoris m. Femoral L2, L3, L4
Ankle Soleus/gastrocnemius m. Sciatic/tibial S1, S2
Planter Small foot muscles Plantar L5, S1, S2
UMNL LMNL
Brain or spinal cord above the level of the At & below the level of nucleus.
nucleus.
Hyperreflexia. Hyporeflexia.
Clonus. Fasciculation.
Spastic paralysis (hypertonia). Flaccid paralysis (Hypotonia).
Wasting (atrophy)not very prominent. Wasting (Atrophy) prominent feature.
+ Babinski sign. Absent Babinski sign.
Causes of LMNL:
1. Guillain-Barre Syndrome.
2. Diabetic polyneuropathy
3. Motor neuron disease
4. Radiculopathy
Causes of UMNL:
1. Stroke.
2. Multiple Sclerosis.
3. Traumatic Brain Injury.
4.Cerebral Palsy.
Coordination
Poor Visual acuity, Cerebellar Disorders and Sensory loss affect coordination.
i.Heel–shin test:
• Ask the patient to run the heel of one foot up and down on the opposite shin
at a moderate pace and as accurately as possible.
• In Cerebellar disease: The heel wobbles all over the place, with oscillations
from side to side and overshooting.
• Closing the eyes makes a little difference to this in cerebellar disease, but if
there is posterior column loss, the movements
are made worse when the eyes are shut that
mean there is ‘sensory ataxia’.
ii. Toe–finger test:
• Ask the patient to lift the foot
(with the knee bent) and touch your finger
136 with the big toe. Look for intention tremor.
iii. Foot-tapping test:
• Rapidly Alternating movements are tested by getting the patient to tap the sole of the
foot quickly on your hand or to tap the heel on the opposite shin. Look for loss of rhythmic-
ity.
iv.Gait abnormality:
• First make sure that the patient’s legs are exposed.
• Ask him to do multiple walks:
• Walk normally for a few meters.
- Walk heel-to-toe in a straight line. (to exclude a midline cerebellar lesion).
- Walk on toes. (an S1 lesion will make this difficult or impossible).
- Walk on heels (L4 or L5 lesion causing foot drop, will make this difficult or impossi-
ble).
- Ask him to squat (L3, L4) and then stand up, or sit in a low chair and then stand.
v.Romberg test:
• Ask the patient to stand erect, feet together and eyes wide open, once he is stable
(marked unsteadiness with the eyes open is seen with cerebellar or vestibular dysfunction),
ask him to close his eyes for 1 minute. The sign is positive if marked unsteadiness occurs to
the point where the patient looks likely to fall while closing his eyes.
• This is usually seen in patient with the loss of proprioceptive sensation/posterior column.
Sensory System
As for the upper limb, test for pain sensation in each dermatome (L2 - S2),
comparing the right with the left leg.
Test vibration sense over the big toes, if abnormal; try on the knees then the
anterior superior iliac spines.
Test proprioception, using the big toes by asking the patient to close his eyes
and
tell whether you moved the toe up or down.
Finally, the light touch of the dermatomes (from L2 - S2), comparing the right
with the left leg.
137
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138 ....................................................................................
Gastrointestinal System Chapter
Reem Mohamed alghamdi
Rowaina Walid Azizarahman
AnghamMarzouk Ghizna
Asya Rezayq alsulami
Sara Ahmed Al-Edrisi
Esraa Abed alfadhli
Wajd Ramzi Felemban
Hamza Ahmad Alkharoobi
Revised by:
Tharaa Waleed Rambo
140
History of Abdominal Pain
1- Personal Data :
Name, Age, Gender, Nationality, Route of Admission (Through OPD or ER ) ,
Date and Time that the patient was seen.
2- Chief Complaint (CC):

Abdominal pain, Its duration (minutes/hours/days/months/years).
3- History of Presenting Illness (HPI):

SOCRATES + P : (Site, Onset, Character, Radiation, Alleviating Factors, Tim-
ing, Exacerbating Factors, Severity + Progression)
Site:
Where is the pain?
Onset:
- When did the pain start?
- Gradual or Sudden ?
- Duration
Character ( Nature : Burning, Stabbing, Colicky, Steady )
Describe the nature of the pain?
Pain Description DDx

- Comes and goes in waves -Renal colic
- Related to peristaltic movement -Biliary colic
Colicky
•Due to: - Bowel obs.
Obstruction of hollow viscus. - F Tube obstruction
-Constant and persistent until the cause subsides.
-worse by local and general movements. - Acute Pancreatitis
- Perforated Appendix
• Due to: - Perforated Peptic
Steady Inflammation, Ischemia, neoplastic infiltration.
Ulcer
(Note: Inflammation within the Abdomen does not Mesenteric Vascular
throb or burn in the same way that the inflamma-
Occlusion
tory pains do elsewhere)
Radiation:
-Does the pain radiate (or travel) to other sites
Back Groin Lt. Arm Neck
- Gastritis
- Peptic ulcer -Gastroesophagea
- Renal colic
- Pancreatic pain -Esophagitis l reflux disease
- UTI
- Esophagitis (GERD)
-aortic aneurysm
141
History of Abdominal Pain .. cont.
Primary site of
Another Area Example
pain (source)
Patients with a posterior penetrating
duodenal ulcer usually have a per-
Radiation + + sistent pain in the epigastrium, and
the pain may also spread through to
the back.
Inflammation of the diaphragm caus-
Referred pain - + es a pain experienced only at the tip
of the shoulder.
Appendicitis most often presents
with a colicky pain that begins in the
center of the abdomen. But after a
Shifting pain + then - - then +
varying period the pain shifts to the
right iliac fossa and becomes more
severe.
Alleviating Factors (Relieving Factors):

- Is there anything makes you feel better? what is it?
-Factors that improve symptoms (relieve the pain) such as:
particular position, movement, food, antacids, exertion, defecation,
hot-water bottle, and analgesics.
Some examples :
Alleviating Factors Symptoms of
-Antacid
-peptic ulcer pain
-food
-gastroesophageal reflux
-vomiting
-Defecation
-Colonic disease
-Passage of flatus
- Rolling around -Colicky pain
- lying still -Peritonitis
Timing:
Continuous or Intermittent . if intermittent ask about Frequency:
- How many attacks ?
- How long does each attack last ?
duration between attacks ?
Exacerbating Factors (Aggravating factors):

- Is there anything makes you feel worse? what is it?
-Factors that make the pain worse such as:
movement, eating, opening the bowels, particular position
Severity:
-Note: What is a ‘severe pain’ to one person might be described as a ‘dull
ache’ by another. That is why a better indication of severity is the effect
of the pain on the patient’s daily life:
142
- Did it stop the patient going to work?
- Did it make the patient go to bed?
- Did they try proprietary analgesics?
- Did they have to call their doctor?
- Did it wake the patient up at night, or stop them going to sleep?
- Was the pain better lying still, or did it make them roll around?
The answers to these questions provide a better indication of the
severity of a pain than words such as mild, severe, agonizing or terri-
ble.
- Or you can ask the patient about the scale of the pain severity from (1-
10).
Progression:
Same, Better, Worse.
Ask about them. If any are present, get details:
•GIT: Anorexia and Weight Loss - Postprandial Fullness or Early Satiation -
Choking - Dysphagia - Odynophagia - Water Brash - Regurgitation - Heart Burn
- Dyspepsia - Abdominal Distension - Nausea & Vomiting (amount – color – How
many times - content - Related to food) - Hematemesis - LGI Bleeding - Al-
tered bowel habit (Diarrhea - Constipation)
• Jaundice Symptom: ( Yellowish Discoloration, Dark Urine , Pruritus, Pale
stool, Lethargy, Fever)
• Anal Complaints:Prolapse -Bleeding -Mucus Discharge Anal and Perianal Pain
Swelling -Discharge and Pruritus
• GUT: Pain (Flank - Loin – Suprapubic) - Dysuria (UTI) Polyuria / Oliguria -
Nocturia - Urgency / Frequency - Hesitancy - Incontinence - Urine Color - He-
maturia Vaginal Discharge (PID)
• Menstrual History: Regularity, Frequency, Duration, Quantity, Dysmenorrhea
(Pain during Period), Menorrhagia, Amenorrhea.
• Exogenous Hormone Use (Oral contraceptive pills - Hormonal therapy)
5- Risk Factors :
- Medication e.g. NSAIDs
- Excess coffee, alcohol, smoking
- Prior abdominal surgery
- Previous blood transfusion
- Any condition that compromise the immune system: (Diabetes - Organ trans-
plant - Chemotherapy - AIDS - Sickle cell anemia)
1- Fever,
2- Fatigue
3- Weight loss
4- Loss of appetite
5- Night sweating 143
[Ask about other systems and ask about other symptoms in different sys-
tems whether related or not].
●DO you have :( Chest pain , Dyspnea , Orthopnea, PND , Palpitations ,
Syncope , Ankle swelling , Easy fatigue , Intermittent claudication , Cold
extremities , Cyanosis ) (CVS)
● DO you have :( Wheeze , Cough , Sputum , Hemoptysis , Chest pain , Dys-
pnea , Hoarseness of voice, Sore throat ) (Respiratory)
● DO you have :( Headache , Neck pain ,Visual disturbance , Seizures , Limb
weakness ) (CNS)
● DO you have :( Dysuria , Hematuria , incontinence , polyuria ) (GU)
●DO you have :( Joint pain , Bone pain , Anemia ) ( Hematology + Rheumatol-
ogy )
●DO you have :( Bruising, Itchiness ,Color changes, Rashes, Swelling) ( Skin)
8- Past Medical History :

-Any chronic diseases? (DM - HTN - IHD - TB - Liver or Renal diseases - cancer-
IBS - IBD)
-Previous hospitalization (Why?).
9- Past Surgical History:

10- Drug and Allergy:

-Any drug that the patient is using? (Mention the relevant)
-Allergies to food, drugs, dust.. Etc.
11- Family History:

- Chronic diseases in the family (mention the relevant)
- Genetic diseases
- Cancer
12- Social History:

-Educational Level
-Occupation
144 And if related, ask about:, Sexual contact, Pets, Diet and Physical activity.
13- Differential Diagnosis (DDx)
A. According to the Quadrants of the Abdomen (Site) :
Upper abdominal pain
Rt. hypochondrium Epigastrium Lt. Hypochondrium
1-Biliary colic:
- Fertile fat female in her 40s (the 4 Fs).
-Severe, dull (not colicky), constant.
- radiate to the Rt. scapula or Rt. shoul- 1-Pancreatitis:
der (C3 & C4 dermatome). -Sudden.
-The pt. can’t stay still. -increasing severity -ra-
1-Splenic seques-
-increase By fatty food. diate to the back.
tration:
- Nausea &vomiting. -(-ve) Murphy’s sign. -by movement.
- sickle cell anemia
2-Cholecystitis: - Nausea & vomiting.
patients.
-30-60 yrs or younger pt’s - Past Hx of gallstones.
- Splenomegaly.
-with sickle cell anemia. -Serum amylase > 1000
2- Splenic rupture.
- continuous. units
-radiate to the tip of the -GREY TURNER SIGN
Rt. scapula.
-increase by movement & breathing
-decrease by analgesics.
-Nausea, vomiting & fever.
Central abdominal pain

Rt. lumbar Umbilical Lt. lumbar
1-Pyelonephritis: 1-Pyelonephritis:
1-Bowel obstruction -High SB
- Female > Male - Female > Male
→ sever colicky pain.
- Sudden. - Sudden.
-vomiting (green fluid)
-sever (one or both sides). -sever (one or both sides).
- minimal distention & rarely
- Dysuria. - Dysuria.
absolute constipation. Low
-frequency -frequency
level distention, absolute
-malaise -malaise
constipation, infrequent col-
- fever & sweating. -Nausea - fever & sweating. -Nausea
icky pain & late vomiting
& vomiting. -Bacteremia, & vomiting. -Bacteremia,
2-Early stage of Appendicitis
pyuria pyuria
Lower abdominal pain

Rt. lumbar Umbilical Lt. lumbar
1- Diverticulitis:
1-Appendicitis:
- Gradual mild intermittent
- vague, begins around the 1-Hypogastric Salpingitis:
lower abd pain then shift to
umbilicus then shift to the -Gradual
Lt. iliac fossa and becomes
Rt. iliac fossa. -constant
more sever &constant ache.
-Nausea& vomiting. -radiate to the lower back
- Nausea (no vomiting) -loss
-(+ve) Mcburney’s, Rovs- -Rigors &sweating -History of
of appetite -constipation.
ing’s, dysmenorrhea.
-History of diverticular dis-
-psoas & Obturator signs -History of infection.
ease.
-High WBCs (neutrophils)
-(+ve) reversed Rovsing’s sing
145
B. According to the Pattern of Pain :

Peptic ulcer Pancreatic
Biliary pain Renal colic. Bowel obstruction
disease pain
(more than
(4 – 24 hours). (1/2 – 2 hours)
2 hours)
It is a burning
It is steady It is rarely col- It is a colicky It is a colicky pain.
pain in the epi-
epigastric pain icky. It is epi- pain in the Associated with vom-
gastrium.
and relieved gastric pain. It renal angle. iting, constipation and
It occurs at
by sitting up may progress Radiates abdominal distension.
night and
and leaning and cause toward the Small bowel obstruc-
wakes the
forward. It cholecystitis groin. Asso- tion is more frequent
patient from
is associated and the pain ciated with pain (with cycle every
sleep. Associat-
with vomiting is shifted to vomiting, he- 2-3 min). Large bow-
ed with upper
and paralytic the right upper maturia and el obstruction (10-15
GI bleeding.
ileus. quadrant. dysuria. min).
146
History example
CC:
The patient is a 62 yo old female with a 2 day history of worsening abdom-
inal pain and distension.
HPI:
The patient states that for the past five days she has felt bloated and has
had a decrease in appetite. Two days ago she began having intermittent
abdominal pain that initially felt like gas pains but it has now progressed
to being nearly constant. Since yesterday she has had severe nausea and
has had 4 episodes of bilious vomiting despite not having taken anything by
mouth in over 24 hours. Her last bowel movement was over five days ago.
She has a history of intermittent constipation but never with this level of
pain, the vomiting, or the bloating. She has a history of multiple abdominal
surgeries. Initially, when she would eat the pain would increase but she
has not eaten anything for over 24 hours. Vomiting is the only thing that
seems to provide some minimal relief. Currently, the pain is described as
a constant dull, diffuse pain that intermittently becomes sharp and well
localized. The sharp pain tends to occur in different locations at different
times. The intensity of the pain has been increasing over the past two days
and on pain scale she now rates the pain at 8 out of 10. She denies a recent
history of fever, jaundice, pruritis, diarrhea, hemoptysis, melena, or he-
matochezia. She denies a known history of hemorrhoids, diverticulitis, co-
lon cancer, peptic ulcer disease, gastritis, acid reflux, gall bladder disease
or cholelithiasis. She denies a history of smoking or alcohol consumption.
PMH:
Hypertension. History of benign ovarian cyst. No history of colon cancer,
diabetes, renal disease, lung disease, bleeding disorders, blood dyscrasias,
heart disease, or other cancers.
Surg Hx:
1)Appendectomy at age 18 yo.
2)Right ovary excision at age 51 yo.
3)Hysterectomy at age 58 yo
Allergies:
NKMA
Medications:
lisinopril 10mg, hydrochlorothiazide 25mg.
Social Hx:
Lives with husband, married for 40 years. Non-smoker, non-drinker.
Family History:
Son, age 41, alive and well.
Mother, 80 yo, history of HTN and stroke.
Father, died at 81 yo from MI, history of HTN and hyperlipidemia.
147
ROS:
Constitutional- no fever or decreased energy Skin- No rashes, dryness,
pruritis, or jaundice. Head- No headaches, dizziness, or syncope Eyes- No
vision changes or pain
Ears- No tinnitus or changes in hearing
Nose- No congestion or rhinitis. No epistaxis.
Mouth/Throat- So throat soreness and dryness. No oral sores or dyspha-
gia. Neck- No pain or swelling.
Respiratory- No wheezing, coughing, orthopnea Cardiovascular- No chest
pain, palpitations, edema, or syncope. GI- As above
GU- No dysuria or hematuria. No nocturia.
Endocrine- No history of diabetes, polydipsia, or polyuria. Heat or cold
intolerance .
148
History of Abdominal Distention
1- Personal Data :
Name, Age, Gender, Known chronic illness, Nationality.
2-Chief Complaint :
Abdominal mass\distension, Ask about: Duration of symptoms?
Rout and time of admission? (Through ER or clinics) .
3- History of Presenting Illness (HPI) :

Site:
Is it generalized (distension) or localized (mass)?
If localized \ at what region?
Onset :
Did it start suddenly or gradually?
Progression :
Is it getting worse, better or just the same ?
Character :
Is it persisting all the time ? or on and off ?
Relieving factors :
Is it relieved by anything ? by defecation ? or by pressing on it ?
Aggravating factors :
Is there anything you do that make it worse ?
Timing :
Does it appear in certain situations? (as in hernia, it appear with lift-
ing heavy stuff, recurrent intense attacks of coughing or with defe-
cation) .
4- Associated symptoms :
•GIT (from mouth to rectum) , Ask about : Abdominal pain, Nausea, Vomit-
ing, Hematemesis ( portal HTN ), Jaundice ( sickle cell anemia, hepatitis, bile
duct obstruction ), Stool changes ( diarrhea, constipation “hernia”, blood in
the stool “parasite, tumor”, color of the stool “bile duct obstruction” )
•Genitourinary tract : Abdominal/pubic pain ( kidney ), Urination (F-CHIP).
5- Constitutional symptoms :
•Fever
• Loss of weight
•Loss of appetite Urination (F-CHIP) :
•Fatigue F: frequency
C: color
•Night sweating H: hematuria
I: incontinence
P: painful urination
6- Risk factors :
•Any recent travel ? to where ?
•Any recent trauma ?
•Alcohol: Do you drink alcohol ? How much ? for how long?
149
History of Abdominal Distention .. cont.
7- Systematic review :
• CVS: chest pain, dyspnea, orthopnea, PND, intermittent claudication,
cyanosis, syncope, lower limb edema .
• Respiratory: chest pain, dyspnea, runny nose, hemoptysis, wheeze,
stridor .
• CNS: seizure, headache, drowsiness, weakness, abnormal movement .
• Hematological: pallor, jaundice, bone pain, bruises, bleeding from nose
• Musculoskeletal: joint swelling, joint pain, skin rash .
8- Past medical/surgical history :

• Have you any previous similar condition ?
• Do you have any chronic disease ? (DM, HTN, SCA, hepatitis, HF)
• Do you use any medications ?
• Do you have any known allergies ?
• Have you received all your vaccination ? (TB, hepatitis)
• Any previous hospitalization ?
• Any previous surgery in GIT or GUT ?
• Have you received any blood transfusion ?
9- Family history :
• Do you have a similar condition in your family ?
• Do you have any chronic or inherited diseases in the family ? (SCA, CF)
• Is there a family history ?
10- Social history :

• Smoking (active, ex-smoker or passive)
• Marital status
• Educational level
• Occupation
•Address
11- Differential Diagnosis of Abdominal Mass :

Region Differential diagnosis
Right hypochondriac - Liver (hepatomegaly, tumor) .
region - Gallbladder (empyema) .
Left hypochondriac re- - Spleen (splenomegaly) .
gion - Pancreas (pseudocyst, tumor) .
- Stomach ( carcinoma of the stomach, pyloric stenosis, acute
Epigastric region gastric dilation in DKA or after surgery, gastric distension).
- Epigastric hernia .
Rt. Kidney (PCKD, hydronephrosis, cyst, tumor).
Right lumber region
Colon (carcinoma, volvulus, intussusception) .
Umbilical region Umbilical or Para umbilical hernia .
Lt. Kidney (PCKD, hydronephrosis, cyst, tumor) .
Left lumber region
150 Colon (carcinoma, volvulus, intussusception) .
History of Abdominal Distention .. cont.
11- Differential Diagnosis of Abdominal Mass .. cont. :

1-Appendix (abscess, mucocele of the appendix, mass) .
2-Carcinoma of the cecum or caecal distension due to distal obstruction
Right iliac fossa 3-Gynecological (ovarian cyst, ovarian tumor, ectopic pregnancy) .
Crohn’s disease (usually when complicated by an abscess) .
4-Hernia .
1-Feces .
2-Carcinoma of sigmoid or descending colon.
3-Gynecological (ovarian cyst, ovarian tumor, ectopic pregnancy) .
Left iliac fossa
4-Diverticular phlegmon or abscess .
5-Hernia
6-Psoas abscess .
1-Bladder (retention, tumor) .
2-Uterus (pregnancy, tumor) .
Suprapubic
3-Bowel (colorectal carcinoma, 4-Crohn’s disease)
5-Small bowel obstruction .
1-Lipoma .
Some causes of
2-Sebaceous cyst .
anterior ab-
3-Dermal fibroma .
dominal wall
4-Rectus sheath divarication .
causes:
5-Rectus sheath hematoma .
Differential diagnosis of abdominal distension :

Physiological (5'F) Pathological
• Non-obstructive causes :
1- Ascites (HF, nephrotic syndrome, cirrhosis) .
• Fat
2- Intra-abdominal bleeding (e.g. ruptured aortic aneurysm) .
• Fetus
• Obstructive causes :
• Flatus (gases)
1- Neoplasm (intraluminal, extraluminal) .
•Feces
2- Infection (parasitic) .
•Fluid
3- Miscellaneous (adhesion, volvulus, intussusception)
4- Foreign body .
151
History of Upper GI Bleeding
Introduce yourself; take permission from the patient to take Hx
1- Personal Data:
Name, Age, Sex, and Nationality
2-Chief complain:
Hematemesis and/or Melena. Ask about the duration of symptoms. Ask about
route and time of admission.
3- History of presenting illness:

For fluid: DOQ AAAAC
Duration( when did it start? )
Onset( Did it start suddenly or gradually? )
Quality ( character – course’frequency’, progression, amount, blood\mu-
cus, colour\content, odor )
Aggravating and alleviation factors?
Associated Symptoms?
• GI symptoms from mouth to anus
( dysphagia - odynophagia – heart burn – nausea and vomiting – ab-
dominal distension – abdominal pain – jaundice – hematochezia )
• Is there any spontaneous bruising or bleeding from other sites?
• Recent Hx of epistaxis or hemoptysis? ( swallowed blood )
•Peripheral edema? (liver disease)
Attribution (precede by several forceful vomiting episodes? )
Complications
4- Associated symptoms:
Mentioned above.
5- Constitutional symptoms:
( fever – loss of weight – loss of appetite – fatigue – night sweating )
6- Systemic review:
- CNS: headache – irritability
- CVS: chest pain – palpitation – SOB – PND – orthopnea – calf claudication
- Respiratory : rhinorrhea – ear pain – throat pain - SOB – cough – wheeze
- Urinary: frequency – dysuria – hematuria
- Genital: pain – discharge
- Musculoskeletal: joint swelling or pain – bone pain
- Hematological: pallor – bruises
- Skin: rash – itching
7- Past medical Hx:

• Any previous similar condition?
• Previous admission? ( when? Why? What happen? )
• Is there any Hx of chronic disease?
152
History of Upper GI Bleeding .. cont.
8- surgical Hx:
• any previous operation? ( type, when, complications, outcome )
• any blood transfusion?
9- Drug and allergy Hx:

•Any drug that the patient is using? ( Is there Hx of steroid or NSAID or antico-
agulant? )
• Allergy to food, drugs, dust..etc
10- Family Hx:

• Hx of similar complain in the family?
• Hx of any chronic disease?
• Hx of any genetic disease?
• Hx of cancers?
11- Social Hx:

• Hx of alcohol?
• Hx of smoking? Either active or passive ( ask about type, duration, no. of
packs per day then calculate it in pack-year ) or Ex-smoker ( for how long? )
• Marital status?
• Educational level?
• Occupation? ( what do you do for living )
• Address? ( where do you live )
• Travelling? • Hematemesis cause by
lesion proximal to the duo-
• Immunization? deno-jejunal junction.
• Common causes of upper
GI bleeding in adult :
12- DDx of upper GI bleeding: 1- PUD
•Reflux esophagitis: 2- Congenital lesion
Small volume 3- Varices
Bright red
Associated with regurgitation
• Esophageal carcinoma:
Scanty
Blood stained debris • Common causes of upper
GI bleeding in erderly:
Associated with dysphagia and Weight loss 1- Tumors
• Bleeding varices: 2- PUD
Esophagus 3- Angiodysplasia
Sudden, painless
Large volume
Dark or bright red
Hx of alcoholic liver disease
Features of portal HTN
•Mallory-Weiss syndrome:
Bright red
Precede by several normal but forceful vom-
iting episodes
153
History of Upper GI Bleeding .. cont.
12- DDx of upper GI bleeding .. cont. :

• Erosive gastritis:
Small volume
Bright red
Hx of dyspepsia
May follow alcohol or NSAID
• Gastric ulcer:
Stomach
Large volume, painless
Accompanied by altered blood ( coffee ground )
Hx of PUD
• Gastric cancer:
Anemia
Associated with weight loss, anorexic, dyspeptic symptoms
• Deodenitis:
Small volume
Bright red
Hx of dyspepsia
May follow alcohol or NSAID
Duodenum
• Duodenal ulcer:
Past Hx of duodenal ulcer, melena
Back pain
Hunger pain
NSAID use
Systemic bleeding disorder.
Epistaxis.
Others
Hemoptysis.
Foreign object.
154
History of Lower GI Bleeding
Introduce yourself, take permission from the patient to take Hx
1- Personal Data:
2- Chief complain:
( bleeding per rectum or bloody stool ).Ask about the duration of symptoms
Ask about route and time of admission.
3- History of presenting symptoms:

For fluid: DOQ AAAAC
Duration( when did it start? )
Onset( Did it start suddenly or gradually? )
Quality ( character – course’frequency’, progression, amount, blood\mu-
cus, colour\content, odor )
Aggravating and alleviation factors?
Associated Symptoms?
• GI symptoms from mouth to anus
( dysphagia - odynophagia – heart burn – nausea and vomiting – ab-
dominal distension – abdominal pain – jaundice – hematochezia )
• Is there any spontaneous bruising or bleeding from other sites?
•Recent Hx of epistaxis or hemoptysis? ( swallowed blood )
•Peripheral edema?
Attribution: pain during of after defecation, irritation, pruritus ani )
Complications
Mentioned above.
( fever – loss of weight – loss of appetite – fatigue – night sweating )
6- Systemic review:
7- Past medical Hx:
• Any previous similar condition?
• Previous admission? ( when? Why? What happen? )
• Is there any Hx of chronic disease? 1
History of Lower GI Bleeding .. cont.
8- surgical Hx:
• any previous operation? ( type, when, complications, outcome )
• any blood transfusion?
9- Drug and allergy Hx:

• Any drug that the patient is using?(Is there Hx of steroid or NSAID or antico-
agulant? )
• Allergy to food, drugs, dust..etc
10- Family Hx:

• Hx of similar complain in the family?
• Hx of any chronic disease?
• Hx of any genetic disease?
• Hx of cancers?
11- Social Hx:

• Hx of alcohol?
• Hx of smoking? Either active or passive ( ask about type, duration, no. of
packs per day then calculate it in pack-year ) or Ex-smoker ( for how long? )
• Marital status?
• Educational level?
• Occupation? ( what do you do for living )
• Left sided/sigmoid bleed-
• Address? ( where do you live ) ing is characteristically
• Travelling? bright red associated with
• Immunization? defecation.
• Proximal colonic/ileal
bleeding is usually dark red,
12- DDx of lower GI bleeding: fully mixed with the stool or
• Meckel’s diverticulum: occult.
In children and young adult
Painless
Dark red
•Common causes of low-
• Intussusception: er GI bleeding in chil-
Colicky abdominal pain dren :
Retching 1. Anal fissure
2. Meckel’s diverticulum
Small intes- Bright red 3. Intussusception
tine Mucus stool
• Ischemic:
Severe abdominal pain
• Common causes of lower GI
• Tumor ( leiomyoma/ lymphoma ): bleeding in elderly:
1. Colorectal tumor
Intermittent Hx 2. Diverticular disease
3. Angiodysplsia
•Enteritis. 4. Colonic ischemia
5.Anal causes ( hemorrhoid,
fissure, proctitis )
156 6. Colitis
History of Lower GI Bleeding .. cont.
12- DDx of lower GI bleeding .. cont. :
• Angiodysplasia:
- Elderly - Painless -Large volume -Fresh and clots mixed
• Diverticular disease:
- Spontaneous -Painless -Large volume - Fresh blood
- Previous Hx of constipation
Colon • polyps/ carcinoma:

- change in bowel habit - blood mixed with stool -anemia
• Ulcerative colitis:
- Blood mixed with mucus -Intermittent -Diarrhea
• Ischemic colitis:
- Elderly -Severe abdominal pain -Bloody diarrhea
• Carcinoma of the rectum:
Change in bowel habit
• proctitis:
Rectum - bloody mucus - purulent diarrhea in infected -perianal irritation
• Solitary rectal ulcer:
- Bleeding post defecation - Small volume -Mucus discharge
- Feeling of lump in anus
• Hemorrhoids:
Bright red
Post defecation
Stop spontaneously
Perianal irritation
• Fissure in ano:
Children and young adult
Extreme pain on defecation
Small volume
Bright red blood on stool and toilet paper
Anus • Carcinoma of the anus:

Elderly
Mass in anus
Anal pain
Unhealing ulcers
• Fistula in anus:
Recurrent episodes of pain
Minor bleed
Watery or purulent discharge
Pruritus ani
Hx of perianal abcess
Associated with crohn’s disease
157
History of Jaundice
NOTE :
• The normal serum bilirubin is below 17 mol/L(1 mg/dL)
• Excess bilirubin become clinically detectable when the serum level rises
to over 35 mol/L(2 mg/dL) , and give a yellow tinge to the sclera and
skin, termed jaundice .
• So , jaundice is a yellowish discoloration of sclera , skin and mucus
membranes , when the bilirubin level is about (2 to 3 mg/dL)
When taking a clinical history from a patient presenting with jaundice be
sure to ask about the following;
1- Personal data ;
Name ,age , gender , nationality , known chronic illness.
2-Chief Complaint & Duration:

Yellowish discoloration of eyes and/or skin, Ask about the duration of symp-
toms Ask about route and time of admission.
3- History of Presenting Illness:

- When 1st noticed?
- Who noticed it? And where? And how?
- Continuous or intermittent.
● If intermittent ask about:
[Frequency - Duration of each attack - Period between attacks]
- Progression :
● is it getting worse, better or just the same .
4- Associated Symptoms:
● GIT: Anorexia and weight loss -Heart Burn- Regurgitation - Abdominal Pain
-Abdominal Distention-Nausea & Vomiting- Diarrhea or Constipation
● Hematological symptoms : dyspnea ,weakness ,easy bruising or bleeding
,dizziness ,L.N enlargement ,bone pain ,rash ,pale skin .
● GUT: Dysuria, hematuria, change color of urine / or stool (dark urine & pale
stool)
● CVS: Easy Fatigability, tachycardia, SOB (hemolytic disease)
● Abdominal pain or pain after eating
● Change of color of urine and stool (dark urine & Pale stool)
● Pallor
● Bruising
● Itchy
● nausea
● vomiting
158
History of Jaundice .. cont.
5- Risk Factors:
- Contact with Jaundiced Person (hepatitis patient)
- Trauma history
- Eating Outside (ingestion of raw shellfish “hepatitis A” ).
-Traveling (endemic areas with hepatitis A)
- Drug
● Induced hepatitis (paracetamol , rifampin , acetaminophen ,NSAID,
isoniazid)
● Induced cholestasis (steroid , OCP and chlorpromazine)
- history of IV drug Abuse (hepatitis B,C)
- Smoking
- Alcohol (liver failure)
- Sexual Intercourse(hepatitis B,C)
- history of Hepatitis - Gallstones - Pancreatitis
- history of Splenectomy - Cholecystectomy
- Hemolytic Anemia (hepatitis B,C)
- Blood transfusion(hepatitis B,C)
- skin tattoos and piercings (hepatitis B)
- history of sharing razor blades or toothbrushes (hepatitis B)
- immunization (immunized against hepatitis B)
- history of exposure to radiation (hepatic cancer risk)
[Fever, Night Sweating, Fatigue, Loss of Appetite, Loss of Weight.]
7- Systemic Review:
[You should ask full systemic review and concentrate on the related System
(GI – GUT – CVS and hematological symptoms)].
Other systems include:
- Do you have : chest pain, SOB, cough, wheezing, runny nose ? (Respiratory)
- Do you have : headache, neck stiffness, visual disturbance, seizures ? (CNS)
8- Past Medical Hx:

- Chronic disease (DM, HTN, Liver disease, gall stone, hemolytic anemia,
esophageal varices, PHTN)
- Previous similar episode
- Previous admission (why ,where ,and what happened ?)
- Immunization against hepatitis B
- Contact with patient with jaundice or liver problem.
9- Past surgical Hx:

- Previous surgery (biliary surgery)
- blood transfusion.
159
History of Jaundice .. cont.
10- Drug & Allergy:
- Drug [paracetamol, Rifampin, acetaminophen, NSAID, isoniazid]
● taking any medication? Now or in the past? (Doses, how many times/
day, for how long, any side effects?)
- Any known allergies
● Do you have any allergies? (Food (beans), drugs, dust, smells..etc.)
11- Family History:
- history of Hepatitis, jaundice and hemolytic anemia.
- history of similar complaint in the family?
- chronic disease in the family (DM, HTN, liver disease, gallstones and hema-
tological disease)
- family history of a congenital or a genetic disease?
- family history of cancer?
- family history of surgical operation (splenectomy, cholecystectomy)?
12- Social History:
Place of Living -Educational level - Occupation - Marital status - children -
consanguinity - Alcohol abuse (how long & much) - IV drug Abuse - smoking
(active or X-Smoker or passive) - sexual behaviors - Travel history.
13- Summary :
Patient’s ID, chronic illness (known case of…), chief complaint & duration,
important positive and negative symptoms.
e.g. :
Mr. yellow American 20 y.o male . K/C of DM came to ER complained of yel-
lowish discoloration of eyes and skin for a month. +ve to Loss of appetite,
Muscle aches and pains, Nausea and vomiting, Low-grade fever, Dark urine,
Light-colored bowel movements, Itchy skin and +ve history to recent travel to
Africa for 3 month of volunteering.
14- Differential Diagnosis of Jaundice :

PRE HEPATIC HEPATIC POST HEPATIC
Common:
Common:
1. Viral hepatitis.
1.Common bile duct obstruction by:
2. Acute and chronic liver
1. Hemolytic disease ● Gallstones.
failure.
secondary to: ● Carcinoma of head of pancreas.
3. Hepatotoxins.
● Sepsis.
4. Alcoholic liver disease.
● Drugs. Less common:
● Hematological dis- 1. Acute cholangitis.
Less common:
ease (SCA, G6PD defi- 2. Pancreatic pseudocyst.
1. Congenital liver dis-
ciency, thalassemia) 3. Primary sclerosing cholangitis.
ease. (Gilbert’s syndrome,
● Transfusion reac- 4. Common duct strictures caused by
Crigler-Najjar syndrome).
tion. previous surgery.
2. Hemochromatosis.
2- Hypothyroidism. 5. Tumors
3. Primary biliary cirrho-
(cholangiocarcinoma , ampullary tu-
sis.
160 4. Steatohepatitis.
mor and duodenal tumor).
History of vomiting
Introduce yourself, take permission from the patient to take Hx

1- Personal Data :
2- Chief Complaint (CC) :

Vomiting , Its duration (minutes/hours/days/months/years)
3- History of Presenting Illness (HPI):

Onset:
when did it start?
It’s start suddenly or gradually?
Duration :
For how long?
How many time per day?
Quality:
1-Amount If little: seen with gastritis
If large: seen with peptic ulcer
2-Was it projectile? NO
If yes: increase intracranial pressure, Bowel obstruction.
3- what is the color of vomitus? Green: gall bladder disease
Fresh blood: esophageal varices , Mallory Weiss tear.
Coffee ground : peptic ulcer
4- what is the content of your Old food: pyloric stenosis
vomitus? Bilious: small bowel obstruction , gall bladder disease
Fecal : large bowel obstruction
Time:
- Early morning: pregnancy, increased intracranial pressure
- after fatty meal: gall bladder disease
- After restaurant food: poisoning
- After severe coughing: chronic chest infection
Related to food or not?
Is it aggravated and / or relived by anything?
4- Associated Symptoms:
- All symptom of GIT :(abdominal pain or distention , dysphagia , heartburn ,
odynophagia , hematemesis , dyspepsia , jaundice , diarrhea , constipation ,
lower GI bleeding , anal problems , etc. )
- All symptom of CNS : (headache , neck stiffness , fever , weakness , loss of
consciousness , blurred vision , seizure , drowsiness, etc.)
161
History of vomiting .. cont.
5- Risk factors:
- Drugs: Narcotic analgesics, Aspirin, NSAIDs, Iron, Antibiotics.
- Chemotherapeutic agents
- Alcohol
- Acute infection especially in children.
- Pregnancy.
- DKA.
-Uremia.
6- Constitutional Symptoms:
7- Systemic Review:
- Cardiovascular system: (Intermittent claudication, Chest pain, Easy fatiga-
bility,Palpitation, PND, Dyspnea, Cold extremities, Ankle swelling,Orthopnea,
Syncope, Cyanosis)
- Respiratory system: (Hoarseness of voice, Wheeze, Dyspnea, Cough, Spu-
tum,Hemoptysis, Sore throat, Chest pain, Fever, Night sweat)
- Genitourinary: ( pain, urgency, Incontinence, interrupted stream, Discom-
fort, Hesitancy, Weak stream, post-void dribbling, Dribbling, Blood in urine,
Changes in quantity & color, Incomplete emptying, Frequency, Retention)
- Endocrine: (Thirst, Sweating, Prefer hot or cold weather, Fatigue, Neck
swelling, Hand trembling, Skin, hair & voice changes)
- Hematology: (Jaundice, Bone pain, Symptoms of anemia (dyspnea, fatigue,
headache, faintness, palpitation…, postural dizziness), Easy bruising, Skin
rash, Paresthesia, Prolonged bleeding,
Neck/axillary /inguinal swelling ( lymph node) Skin Bruising, Itchiness, Color
changes, Rashes, Swelling.
8- Past Medical History (PMH):
-Any chronic diseases? (DM , HTN ,TB , liver or renal diseases, irritable bowel
syndrome )
-History of contact with febrile patient ?
Past Surgical History (PSH)
-Any drug that the patient is using? (doses, how many time/day, duration ,side
effects)
10- Family History:

-Family history of similar symptoms , Chronic diseases in the family , Genetic
162 diseases , Cancer .
History of vomiting .. cont.
-Educational Level
-Occupation
-Travelling & Immunization, Pets, Diet and Physical activity.
12- Summery:
(the most important negative and positive)
Amal 17 years old Saudi pt came to ER today complaining of vomiting for 8
hours. the symptom associated with fever and pain in right iliac fossa started
around the umbilicus then shifted to right side and nausea ,loss of appetite no
diarrhea no constipation , no change in color of stool or urine.
13- Differential Diagnosis of Vomiting :
- Appendicitis (pain starts in periumbilical area then move to right iliac
fossa, nausea, anorexia, low grade fever, loss of appetite, constipation).
- Cholecystitis(constant right upper quadrant pain, low grade fever, fatty
food intolerance, dark urine and clay stool, jaundice, Hx of gall stone,
alcohol, rapid weight loss).
- Pancreatitis (epigastric pain radiate to the back, nausea, may be fe-
ver).
- Peptic Ulcer (burning abdominal pain flare at night worse when
Inflammation
stomach is empty and may relieved by alkali food, Nausea or vomiting,
Dark blood in stools/melena, Unexplained weight loss, Appetite
changes, NSAID usage)
- Biliary Colic(dull constant epigastrium or right upper quadrant
abdominal pain may radiate to right scapular region or back, nausea,
fever, pleuritic pain).
- Gastroenteritis (fever, nausea, crampy abdominal pain, watery
diarrhea, History of eating from outside).
- Bowel obstruction (Crampy abdominal pain that comes and goes,
Obstruction nausea, diarrhea, constipation, inability to have a bowel movement or
pass gas, abdominal distension )
- Increased ICP (headache, drowsiness, projectile, early morning
CNS vomiting).
- Migraine (visual aura, unilateral throbbing headache, photophobia).
Psychogenic - Bulimia: is eating followed by self-induced vomiting.
- DKA (polyuria, polydipsia, fatigue, noncompliance with insulin,
hypoglycemic agent, abdominal pain, diet, recent infection, stress)
- Gastric Carcinoma (abdominal pain or fullness, abdominal mass,
difficulty swallowing, weakness or fatigue, weight loss, high grade
Others
fever)
- MI (severe chest pain or epigastric abdominal pain lasting more than
30min not relieved by nitrate, sweating, SOB
Medication :chemotherapy
163
Hx of DYSPHAGIA
1-Personal Data:
2- Chief Complaint(CC):
Difficulty in swallowing, its duration (minutes/hours/days/months/years)
3- History of Presenting Illness(HPI):

Onset:
-Did start suddenly (as forging body) or gradually (as carcinoma in
weeks , achalasia in years)?
Timing:
-Is it intermittent ( eosinophilic esophagitis ,motor problem) or per-
sistent ?
-If intermittent ask about episode, duration of each episode and pe-
riod between the episode.
Progression:
-Is it getting worse(cancer or stricture) , better or just the same?
Site:
-Where does the food get stuck? Please point the area( lower esopha-
gus=mechanical obstruction in the lower esophagus).
Type of food:
-Do you have any difficulties in swallowing solid(cancer, stricture),
liquid or both(achalasia)?Which started first?
Are there any relieving or aggravating factors ?’
› cough or chock on starting to swallow (oropharyngeal dysphagia)
› odynophagia ( painful swallowing)
› Heartburn, acid regurgitation(GERD).
› Hematemesis, anemia.
› Chest pain, asthma (eosinophilic esophagitis), fever.
› otalgia, halitosis, fullness of the neck.
› Neck mass, SOB, hoarseness and stridor.
› Slurred speech, dysarthria, dysphonia, skin rash, joint pain and changes in
the color of fingers on exposure to cold .
5-Ris kFactors :
› About food impaction
› History of prolonged intubation
› History of caustic/corrosives ingestion
›History of foreign bodies.
164
Hx of DYSPHAGIA .. cont.
7- Systemic Review:
REVIEW all systems with special focus on neuromuscular, IG, respiratory and
connective tissue disorders symptoms.
All systems start from head
8- Past Medical History (PMH):

- History of trauma, tumor, long-term reflux disease, thyroid disease and re-
current aspiration pneumonia, neurological disorders .
- Previous hospitalization (Why?)
9- Past Surgical History (PSH):

- Any previous operations? (Type, When, Complications, Outcome)
- Any blood transfusion?

- Any drug that the patient is using? (NSAIDs,kcl,doxy& tetracycline)
- Allergies to food, drugs, dust.. etc.
11- Family History:

- Chronic diseases in the family (mention the relevant(
- Genetic diseases (mention examples if relevant(
- Cancer

- Marital status, and if there are any children
- Educational Level
- Occupation
- Smoking: either passive or active (ask about type, duration, no. of packs
per day then calculate it in pack-year) or Ex-smoker (for how long?)
- Alcohol & Drug Abuse
- And if related, ask about:, Sexual contact, Pets, Diet and Physical activity.
165
Hx of DYSPHAGIA .. cont.
1-
13- Differential Diagnosis (DDx) :

1- Esophageal cancer (Dysphagia starts with Solids and progresses to liquids. Hx
of chronic alcoholism, smoking & weight loss )
2- Achalasia (Dysphasia for BOTH solid and liquids)
3- Esophagitis (Pain on swallowing. Immunocompromised “e.g. HIV, Cor-
ticosteroids”)
4- Systemic Sclerosis -------
5- ‘GERD’ (Cough at nights, Hoarseness, sore throat)
166
History of Diarrhea
Introduce yourself, take permission from the patient to take history.
1- Personal Data :
2- Chief Complain :
Diarrhea. Ask about the duration of symptoms. Ask about the route and time
of admission.
3- History of Presenting Illness (HPI) :

HPI: DOQ AAAAC
- Duration( when did it start? )
- Onset( Did it start suddenly or gradually? )
- Quality ( character – course’frequency’, progression, amount, blood\
mucus, colour\content, odor )
- Aggravating and alleviation factors?
- Associated Symptoms?
•GI symptoms from mouth to anus
(Dysphagia – odynophagia – heart burn – nausea and vomiting – ab-
dominal distension – abdominal pain -(jaundice – change in color of
stool or urine –itching– heamatochezia– melena.)
- Attribution (What makes it happen? (Precipitating factor) Hx of restau-
rant food, Hx of travelling, Hx of taking medication, Hx of same illness in
other family members, Hx of gastric surgery.
Complications: (Dehydration - perianal erythema- ….)
- as mentioned above.
Fever , Loss of weight, Loss of appetite, Fatigue, Night sweating
6- Risk Factor :
As mentioned above.
7- Systemic Review:
All systems start from head
- Skin: rash – itching 167
History of Diarrhea .. cont.
8- Past medical/ Past surgical History:
- Medical (chronic diseases – medications – similar attack – previous ad-
mission when and why?)
- Surgical (any procedure – blood transfusion)
- Allergy (food – drugs – animals – dust - other)
9- Family History:
- Chronic diseases
- Similar symptoms

- Marital status (single – married – divorced)
- Smoking (how many cigarettes / day) – alcohol use
- Education level
- Ethnicity
11- Differential Diagnosis of Diarrhea :

- Infectious ( bacterial – viral – protozoal )
- Non infectious
- Inflammatory ( ulcerative colitis – Crohn’s disease )
Intestinal - Malabsorption ( e.g. coeliac disease )
- Neoplastic ( carcinoma – villous adenoma )
- Other ( diverticular disease – irritable bowel syndrome –
ischemic colitis )
o Chronic pancreatitis
o Cystic fibrosis
Pancreatic
o Carcinoma
o Pancreatic resection
o DM
Endocrine
o Thyrotoxicosis
o Antibiotics
o Laxatives
o Magnesium containing antacid
Drugs
o NSAIDs
o Cytotoxic drug
o Anxiety
Other
o Diet
168
History of Constipation
Introduce yourself, take permission from the patient to take history.
1- Personal Data:
2- Chief Complain:
Constipation. Ask about the duration of symptoms. Ask about the route and
time of admission.
3- History of presenting illness (HPI) :

Onset: When did it start?
Duration: For how long? (Acute/ chronic)
Course: Is it continuous or intermittent?
Progression: Is it getting better or worse?
Is there an association with abdominal pain?
Severity: Is it severe enough to interfere with the daily activity?
Is there any relieving or aggravating factors
Is there a previous condition of constipation?
4- Associated Symptoms ( GIT symptoms ) :

- Do have difficulty swallowing? Pain during swallowing?
- Do you have heartburn? Regurgitation?
- Do you have abdominal pain? Distension?
- Do you feel nauseated?
- Did you vomit?
- Yellowish discoloration of your skin?
- Change in urine or feces color?
•Passing dark offensive feces (Melena)? Fresh blood per rectum (hematocha-
zia)?
- Pain during defecation?
Fever, Loss of weight, Loss of appetite, Fatigue, Night sweating
6- Risk Factors:
- Previous abdominal surgery.
- Psychological problems.
- Stress related problems
- Hypothyroidism.
- Respiratory: Chest Pain, Dyspnea, runny nose, hemoptysis, wheeze, and stri-
dor
- ENT: Throat infections, Snoring
169
History of Constipation .. cont.
- CVS: Chest Pain, Dyspnea, Orthopnea, PND, Intermittent claudication,

Cyanosis,
Syncope, LL Edema
- Hematological: Pallor, Jaundice, bone pain, bruises, bleeding from nose
- Infections: Skin rash, recent travel, contact with infectious patient
- Musculoskeletal: Joint swelling, joint pain, skin rash
8- Past medical/Surgical History :
- Is there a history of previous similar condition?
- Is there a history of hospitalization?
- Is there a history of trauma? Surgery? Blood transfusion?
- History of DM, HTN, heart disease, cancer and congenital diseases?
9- Drug and Allergy :
- Are you taking any drugs?
(doses , how many times/day, Duration, side effect )
- Do you have any allergies (to food, pets, dust, drugs)
- Family history of same condition?
- Family history of DM, HTN, heart disease, cancer and congenital diseases?
11- Social History:
- Are you married?
- Do you have children?
- Do you smoke? For how long? How many packs per day?
- Do you drink alcohol? For how long? How much?
- What do you do for a living?Where do you live?
12- Differential Diagnosis of Constipation :
Dietary changes Reduced food intake
Bowel Obstruc- o Diverticular disease :
tion Left quadrant abdominal pain, vomiting, bloating
o Colon cancer :
Weight loss, melena, hematochezia, palpable mass in the abdomen
o External compression:
Pressure from nearby organs (pregnancy), or from nearby tumors (fi-
broid, ovarian tumor)
Anal pain o Anal Fissure
o Rectal bleeding, rectal pain, excessive straining
Perianal abscess
o Strangulated hemorrhoids
Paralyzed bowel Seen especially after a recent surgery (paralytic ileus)
Endocrine o Diabetes Mellitus :Polyuria, polydipsia, polyphagia
o Hypothyroidism : Weight gain, dry skin, depression, fatigue, changes
in voice.
Psychological o Anxiety, depression, change is sleep patterns, irritable bowel syn-
170 drome
GIT Examination
WIPPPER:
•Wash Your Hands.
•Permission.
•Privacy.
•Position.
•Exposure.
ABCDEV:
Hand & Arm
- Nail:
1- Clubbing: increased in soft tissue deposition in the distal part of fingers or
toes (inflammatory bowel disease / cirrhosis / coeliac disease / familial club-
bing / idiopathic).
150
2- absence of a closed triangular space :
leukonychia Koilonychias 171

3. Leukonychia: whitened nail bed – indicate hypoalbuminemia (liver
failure / enteropathy).
4. Koilonychias: spooning of the nails – found in chronic iron deficiency
anemia
Palm:
1. Palmar erythema (Liver Palms = Thenar & Hypothenar): reddening of palms
– Chronic liver disease / pregnancy/ thyrotoxicosis/ rheumatoid arthritis /
polycythemia
2. Pallor: compare between your hand and the patent hand – Inspect palmar
creases for pallor (anemia).
3- Dupuytren’s contracture: visible and palpable Thickening and contracture

of the palmar fascia –causing permanent flexion most often of ring fingers As-
sociated with alcohol excess / family history /manual workers
Dorsum:
• Tendon xanthomata: yellow deposits of the lipid in the tendons, it is associ-
ated with type II hyperlipidemia.
Hepatic flap (Asterixis):

1. Ask patient to stretch out arms, with hands dorsiflexed and fingers out-
stretched
2. Ask them to hold their hands in that position for 15 seconds
3. The hands will flap (flex/extend at the wrist) in an irregular fashion if posi-
tive
4. Causes include – hepatic encephalopathy / uraemia / CO2 retention
172
ARMS :
1. Bruising – may suggest abnormal coagulation
– e.g. secondary to liver failure :
2. Petechiae – pin head sized bruises caused by

low platelets – e.g. chronic excessive alcohol
consumption(lead to bone marrow depression),
splenomegaly, acute hepatic necrosis &
hypersplenism
3. muscle wasting — Late manifestation of malnutrition in alcoholic patients.

4. Scratch marks (Excoriations) – caused by sever itching found in patients with
cholestasis (due to bile salt deposition in the skin)
5. Spider nevi:
- Consist of a central arteriole with numerous small vessels, looks like spider’s
legs.
- Found in the area drained by the superior vena cava, so they are found on the
arms, neck and chest wall.
- Pressure applied with a pointed object to the central arteriole causes blanch-
ing of the whole lesion.
- Rapid refilling from the center to the legs (branches) occurs when releasing
of the pressure.
- The finding of more than two or three spider nevi anywhere on the body is
likely to be abnormal.
- Causes: (liver cirrhosis- most frequently due to alcohol consumption - viral
hepatitis - hereditary hemorrhagic telangiectasia) also may found in pregnancy 173
Spider neavi
Face:
• Eye:
1) Jaundice in the sclera.
2)Pallor in the conjunctiva: signs of anaemia
3)Kayser-fleischer ring
o Brownish green rings occurring at the
periphery of the cornea (more on upper pole).
Due to deposits of excess copper typically found in
(Wilsons Disease). We cannot see without slit lamp.
4) Arcus senilis
o Whitish ring around the cornea found in elderly and
diabetic patient due to hypercholesterolemia.
5) Xanthelasma
o Yellowish plaques in the subcutaneous tissue of the
periorbital region due to lipid deposition. More common
in patient with primary liver cirrhosis or cholestasis.
6) Bitot’s Spots: Yellowish keratinized areas on the sclera

= Severe vitamin A deficiency (malabsorption or malnutrition)
174
• Cheek:
1) Salivary gland:
Ask the patient to clench the teeth so that the masseter muscle is palpable;
- The normal parotid gland is impalpable but the enlarged gland is best felt behind the
masseter muscle and in front of the ear.
- Unilateral parotid enlargement: (mixed parotid tumor, tumor infiltration, duct block-
age)
- Bilateral parotid enlargement (mumps, sarcoidosis, lymphoma, alcohol associated
parotitis, malnutrition or severe dehydration)
• Mouth:
1) dental & oral hygiene
2) Perioral pigmentation indicates Peutz-Jegher’s syndrome / Heavy metals
(Lead, Bismuth, Iron.).
3) Angular stomatitis : deficiency of Vitamin B6, B12, Folate or Iron
4) Fetor hepaticus sweet smelling breath, which indicates severe hepatocellu-

lar disease.
5) Gums for bleeding, gingivitis or hypertrophy in (phenytoin, pregnancy, vita-
min c deficiency, gingivitis, leukemia)
6) Oral ulceration : aphthous ulceration in (Crohn’s disease)

7) Cyanosis under the tongue.
175
- Neck:
•Lymph nodes:
Always palpate the neck from behind the patient with the neck slightly
flexed to relax the sternocleidomastoid muscles.
1) Sub mental.
2) Sub mandibular.
3) Pre auricular.
4) Post auricular. the presence of a
palpable enlarged left
5) Cervical (deep & superficial). supraclavicular node
6) Supra& infra clavicular. (Virchow’s node) in
7) Occipital. combination with car-
cinoma in the stomach
8) Axillary. is called Troisier’s
sign.
- Chest:
• Gynaecomastia (Unilateral or Bilateral): Chronic liver disease, Cirrhosis es-
pecially alcoholic or chronic autoimmune hepatitis, Drugs (Spironolactone,&
others e.g. digoxin, Cimetidine especially in cirrhotic patients)
• Spider neavi.
• Body hair distribution.
• auscultate chest and heart.
You should listen to the
chest and heart to make
sure they are not the
cause of abdominal pain
or they have signs of
complication from in-
tra-abdominal pathology
(e.g. pleural effusion in
pancreatitis).
176
LOCAL ABDOMINAL EXAMINATION
• Inspection :
The patient should lie flat, with one pillow under the head, exposed from the
nipples to the pubic symphysis.
It’s better to inspect the abdomen while standing in front of the patient.
Look for 3 S:
1. Symmetry of abdomen and movement with respiration.
2. Scars :
- Which may indicate previous surgery or trauma.
- Older scars are white and recent scars are pink because the tissue
remains vascular.
- Abdominal scars
Laparoscopic surgical scars are now common. Most of these procedures in-
clude a port about 2 cm in length, just above the umbilicus.
o Upper midline.
o Right subcostal (Kocher’s).
o Right paramedian.
o Lower midline.
o Nephrectomy.
o Appendectomy (Gridiron).
o Transplanted kidney.
o Suprapubic (Pfannensteil).
o Left inguinal.
o Umbilical port –laparoscopic surgery
(courtesy of Glenn McCulloch).
3. Striae :
o Common causes :
- Weight reduction.
- Steroids.
- Cushing syndrome.
- Current or recent pregnancy.
4. Shape of umbilicus (inverted, flat, everted).

5. Flanks.
6. Stroma or fistula.
7. Skin lesions (herpes zoster, Sister Joseph nodule).
8. Abdominal distension, causes (6’Fs) :
- Fat. - Fetus.
- Fluid. - Feces.
- Flatus. - Filthy big tumor
177
9. Prominent veins (caput medusa – around the umbilicus).
– Differentiate caput medusa from IVC obstruction?
10. Visible pulsation
11. Visible peristalsis, causes :
- Normal in thin people.
- Pyloric stenosis.
12. Hernia (ask the patient to cough while inspecting hernia orifice).
- Palpation :
Palpation of the abdomen should be performed in a systematic way using the
9 named segments of the abdomen (Anti-clock wise).
Before starting palpation, you should:

o Reassure the patient.
o Warm your hand.
o Ask the patient if there is any tender
area and examine it last.
o If necessary, ask the patient to bend
the knees to relax the abdomen.
o During palpation, maintain the eye
contact to be sure that no tenderness
goes unnoticed.
1.Superficial palpation :
- To detect any tenderness, rigidity, guarding, and superficial masses.
o Guarding (resistance to palpation by contraction of abdominal mus-
cles) may be voluntary or involuntary. Involuntary guarding indicates
peritonitis.
o Rigidity is a constant involuntary contraction. It indicate peritoneal
irritation.
-Done by placing the hand flat over each area and flexing at the meta-
carpophalangeal joints. You should feel whether the abdomen is soft or
not while looking at the patient’s face for any sign of pain. If you feel any
abnormal masses, you should report these to the examiner.
2. Deep palpation :
- For deeper masses and to define those already discovered.
- The same way as superficial palpation but deeper and keep looking to
the patient’s eyes.
Notes:
o Rebound tenderness is said to be present when the abdominal wall is com-
pressed slowly then rapidly released and a sudden stab of pain results.
178
▪ Organomegaly :
- Palpation:
For palpation of the organ’s edge. Use the lateral surface of the forefin-
ger because it is the most sensitive part of the hand.
LIVER:
• Starting at the right iliac fossa pressing upwards towards the right hypo-
chondria, parallel to the right costal margin.
• Asking the patient to breathe in and out slowly through the mouth.
•Trying to time palpation with the patient’s breathing-in.
• With each expiration, the hand should be advanced by 1-2 cm towards
the costal margin.
Findings:
● Normally: the liver edge may be palpable just below the right costal
margin on deep inspiration, especially in thin people.
● Abnormally: If the liver is distended, its edge will move inferiorly with
each deep inspiration striking the lateral margin of the examiner’s fore-
finger, which feels like a light tap. Comments on liver edge (hard or soft,
tender or not, regular or irregular, pulsatile or not)
Liver span: (See Percussion)
Differential Diagnosis “in liver palpation”:

Hepatomegaly
- Metastasis
- Myeloproliferative disease
Massive - Alcoholic liver with fatty infiltration
- Right heart failure
- Hepatocellular cancer
- The Massive causes
- Haemochromatosis
Moderate - Haematological disease- e.g. chronic leukemia, lymphoma.
- Fatty liver- secondary to e.g. DM, obesity, toxins
- Infiltration- e.g. amyloid
- The Moderate causes
- Hepatitis
Mild - Biliary obstruction
- Hydatid disease
- HIV infection
GALLBLADDER:
• Normally: the gall bladder is not palpable.
• Abnormally: If palpable, a bulbous focal rounded mass might be felt be-
low the right costal margin that moves downward with inspiration. Seen in
Obstructive gallbladder.
179
Important signs:
1- Courvoisier’s law: if gallbladder is enlarged and the patient is jaun-
diced, the cause is unlikely to be gallstones. The more likely diagnosis is
carcinoma of the pancreas or lower biliary tree resulting in obstructive
jaundice.
2- Murphy’s sign: should be considered if cholecystitis is suspected. Hold
your fingers under the liver border. Ask the patient to take a deep breath.
A normal response is to complete the deep breath without pain.
(Positive test : descending liver pushes the inflamed gallbladder into
the examining hand sharp pain that prevents further inspiration)
spleen: ( tow hand technique )

• Starting at the right iliac fossa ( not the left iliac fossa or you may miss
a large spleen ), when the patient breath in and out, move your hand in
stages toward the left costal margin.
• the left hand is placed postero-laterally just below the 4th lower rib and
the right hand is placed on the abdomen parallel to the left costal margin.
• as the right hand closer to the left costal margin, the left hand compress
firmly over the rib cage so as to produce a loose fold of the skin, this re-
moves tension from the abdominal wall and enable a slightly enlarged soft
spleen to be felt as it moves down towards the right iliac fossa at the end
of inspiration.
•if you cannot feel the spleen, roll the patient toward you ( make him\
her lie on their right side ) and feel under the left costal margin on deep
inspiration.
kidney:
• balloting technique using both hands
• right kidney: place your left hand on the back of the patient, with the
heel of the hand in the loin then push the kidney forward. Your right hand
should
be in the right upper quadrant anteriorly.
• When palpable, the kidney feels like a swelling with a rounded lower
pole and a medial dent (hilum).
• In the majority of people the kidneys are not palpable but they maybe
palpable in thin people with no underlying renal pathology.
180
It is important to differentiate between an enlarged spleen and
an enlarged left kidney:
Enlarged Kidney Splenomegaly
It has a palpable upper border so, we can Has no palpable upper border so, not possi-
go above it ble to palpate over it
No palpable notch Has palpable notch
Move inferiorly Move inferomedially with inspiration
Floatable(bloating) Not Floatable
Resonant on percussion “it’s retroperitoneal Dull on percussion
organ”
No friction rub friction rub maybe heard
Abdominal aortic aneurysm:

Aneurysms produce an expansile pulsation. In order to feel the expansion,
both hands must be placed on either side of the mass in the umbilical and
epigastric region to confirm that the hands are pushed apart as well as be-
ing pushed upwards. Abdominal aortic aneurysms are truly expansile; which
means that the hands are pushed apart on palpation. This is different from
the transmitted pulsation from a mass overlying the aorta, where the hands
are pushed up and down but not apart.
- Percussion:
Percussion over the abdomen is usually resonant ( called tympany or tympanic
note in surgery) as the bowel and peritoneum are full of gas.
LIVER:
• liver span: Begin percussion over the lungs along the midclavicular line
and move from the area of resonant lung sounds to the areas of dullness.
Mark the area of change (you may ask the patient to use his finger).
• Repeat the same process from right iliac fossa, moving again from res-
onance over the bowel to dullness and again mark the area of change.
Start in the lower right quadrant so as not to miss a greatly enlarged
liver.
• Measure the vertical distance (between the Two Marks you already
done) from the top to the bottom
•[Normal liver span is 8–12 cm]
Loss of normal liver dullness may be caused by:

o Massive hepatic necrosis
o Free gas in peritoneal cavity e.g. perforated bowel
181
spleen:
There are several techniques to percuss the spleen, most importantly:
oCastell’s point:
i. Patient on supine position, percussion in the lowest intercostal space left
anterior axillary line in both expiration and full inspiration.
ii. In normal individuals, this area is resonant on percussion and remains
resonant in full inspiration.
iii. Splenomegaly is indicated when the percussion note is dull or become
dull on full inspiration ( positive castell’s sign )
o Traube’s space ( triangle ):

i. The boundaries of Traube’s space are:
Left anterior axillary line laterally, sixth rib superiorly, and left costal mar-
gin inferiorly.
ii. This area should be resonant on percussion, any dullness indicates pos-
sible splenic enlargement.
Other possible causes of dullness include; left plural effusion or a full stom-
ach after a meal.
o Nixon’s method:
i. Place the patient in right lateral decubitus position
ii. Begin percussion midway along the left costal margin
iii. Proceed in a line perpendicular to the left costal margin superiorly
iv. If the upper limit of dullness extend <8cm above the left costal margin,
this indicate possible splenomegaly.
Conditions to be considered in the differential diagnosis of massive spleno-

megaly include the following:
•Leishmaniasis
•Malaria
•Myeloproliferative disease
•Portal vein obstruction/portal hypertension
•Schistosomiasis
•Niemann-Pick disease
•Mucopolysaccharidosis
•Lymphomas
•Gaucher disease [10]
•Hereditary spherocytosis
•Thalassemias – major, alpha or beta
•Histiocytosis X
182
Conditions to be considered in the differential diagnosis of mild to moderate
splenomegaly include all of the above, as well as the following:
•Bacterial sepsis
•Infective endocarditis
•Sickle cell anemia
•Splenic abscess
•Acute infectious illnesses (e.g.,typhoid, malaria, other tropical diseases)
•Acute viral infections (e.g., infectious mononucleosis)
•Systemic lupus erythematosus
•Tuberculosis
•Angioimmunoblastic lymphadenopathy
•Banti disease
•Congestive heart failure
•Drug reactions with serum sickness syndromes
•Hyperlipidemias
•Idiopathic splenomegaly
•Immune hemolytic anemias
•Immune thrombocytopenic disorders
•Leukocyte disorders
•Ovalocytosis
•Splenic vein obstruction
•Symptomatic human immunodeficiency virus (HIV) infection
•Trypanosomiasis
Ascites :
oShifting dullness : (to detect mild ascites)
When the patient lying flat, start percussing from the midline going away
from you. If the percussion note change (from resonant to dull), hold your
finger in that position and ask the patient to roll towards you. After a few
(10-35) seconds, percuss again over this area and if the note has changed
then it suggest presence of fluid such as ascites.
183
o Fluid thrill : (for massive ascites)
Patient first lies supine in front of the examiner and then another person
(or the patient himself) puts the medial edge of his hand on the middle
of the abdomen to dampen vibration transmitted by the anterior abdom-
inal wall. The examiner’s palm is placed flat on the lumber region of one
side and on the other side he/she taps the abdomen with the forefinger
of the other hand. A distinct impact passes to the flat palm on the other
side if the peritoneal cavity is filled with fluid (Ascites).
▪Differential Diagnosis of Ascites :
Special Test of APPENDIX:

When suspecting appendicitis, the following tests should be done :
Test How to perform ? +ve -ve Explanation
-Choose a site away
Pain on
from the painful area.
release of
Rebound Push down slowly and This makes
pressure →
Tenderness deeply; then left quickly. structures that are
no pain on release rebound
(Blumberg’s -Perform this test at the indented by pal-
of pressure tenderness
sign) end of the examination, pation rebound
→ peritoneal
because it can cause sudden.
inflammation
severe pain and muscle
→ appendicitis
184 rigidity.
cont.
Test How to perform ? +ve -ve Explanation
Iliopsoas m test →
With the patient on
Pain on right lower
his/her left side and Pain on
Iliopsoas quadrant → ilio-
right leg straight, right lower the patient feels no pain
Muscle Test psoas m inflamed
extend the right hip quadrant
→ inflamed or per-
to full extent
forated appendix
With the patient
supine, lift the right Obturator test →
leg, flexing at the irritates the ob-
Pain on
Obturator hip and 90 degrees turator muscle →
right lower the patient feels no pain
Test at the knee. Hold pain on RLQ →
quadrant
the ankle and rotate perforated or pel-
the leg internally vic appendicitis
and externally
Murphy’s Hold your fingers descending liver
sharp pain
sign under the liver pushes the in-
that pre- complete the deep breath
(It is NOT border. Ask the pa- flamed gallbladder
vents further without pain
appendix tient to take a deep into the examining
inspiration
test) breath hand → pain
- Auscultation:
- Might be carried out before percussion and palpation due to adverse effect
that these procedures may have on the sound from the bowels.
Listen to:
1. Bowel Sounds (Borborygmi)
2. Friction rubs (Inflammation of parietal & visceral peritoneum)
3. Venus Hums (A continuous low pithed soft murmur)
4. Bruits (A higher pitched – Not continuous & Well localized)
How to Auscultate
Normal Abnormal DDx
?
Place the dia- Complete absence of
paralytic
phragm of the Bowel sounds any bowel sounds over
ileus
stethoscope just should be de- a 4-minute period
below the umbi- scribed as louder and high-
obstructed
licus at least for either present er-pitched sound with a
1.Bowel bowel sounds
30 sec. -Bowel or absent; the tinkling quality
sounds
sounds can be terms ‘de- (Intestinal hurry or
heard over all creased’ or These bowel
rush) loud gurgling
parts of the ab- ‘increased’ are sounds are
sounds, often audible
domen in healthy meaningless. called borbo-
without the stetho-
people. They are rygmi
scope
185
cont.
How to Aus-
Normal Abnormal DDx
cultate ?
-Hepatic causes: tumour
within the liver (hepatocel-
lular cancer or metastases),
It is heard
a liver abscess, a recent
as the
liver biopsy, a liver infarct,
2. Friction patient A rough creaking
Not present or gonococcal or chlamydial
rubs breathes or grating noise
perihepatitis due to inflam-
over the liv-
mation of the liver capsule
er or spleen
(Fitz-Hugh Curtis syndro-
mez). -splenic rub indicates a
splenic infarct..
-in cases of portal hyperten-
sion, but is rare.
continuous, low-
pitched, soft
Typically -The Cruveilhier-Baumgarten
murmur that may
it is heard syndrome
become louder
3. venous between the (Venus hum at the umbilicus
Not present with inspiration
hum xiphister- + dilated abdominal veins) =
and diminish
num and the Cirrhosis of the liver (intra-
when more pres-
umbilicus hepatic obstruction rather
sure is applied to
than obstruction in portal
the stethoscope
vein itself)
This sound is high- -hepatocellular cancer -acute

er pitched than alcoholic hepatitis, -arterio-
a venous hum, is venous malformation
not continuous -transiently after a liver
and is well local- biopsy
ized.
renal bruits on
either side of the renal artery stenosis is sus-
midline above the pected
can be umbilicus
4. Bruits heard over Not present
the liver may be heard in patients
with chronic intestinal isch-
bruit in the epi- aemia from mesenteric
gastrium arterial stenosis, but may
also occur in the absence of
pathology
A bruit may oc-
tumour of the body of the
casionally be
pancreas or a splenic arterio-
audible over the
venous fistula
spleen
186
To complete your examination:
- You have to check the following:
o Examine the back: for tender costovertebral angle (pyelonephritis)
and sacral edema
o Genitalia and Groin examination for hernia and lymph node
o Digital Rectal Examination (DRE)
References :
• Clinical skills by Nicolas Tally (171-234)
• ABC to clinical book 32
• ABC to clinical book 33
187
For your notes
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188
Lump & hernia chapter
ABDULLAH SULIMAN YAMANI
Afnan ABDULLAH Bassallom
Haneen Mohammad Banjar
Ali hasan al khazaim
Revised by:
190
History Taking of Any lump
First Introduce Yourself to the patient and take the permission
1. Personal data:
Name, Age, Gender, Nationality, Route of Admission (Through OPD or ER)
2.Chief complaint:
A lump or swelling anywhere in the body, Ask about the duration (minutes,
hours, days months, years )
3.HPI:
Site: Where is the lump?
Onset: (sudden/gradual)
-When was it first noticed?
First symptoms: What made the patient noticed it?
- Felt or saw it.
- Pain.
- Someone else notice it.
- Found it on self-examination e.g.: breast lump.
Multiplicity: Has the patient ever had any other lump in other part of the
body?
- e.g. neurofibromatosis or lipomas.
Persistence: Dose the lump ever disappear and reappear?
- If disappear, what make it disappear and Reappear?
- Disappear during lying down or exercise.
- Disappear completely.
Progression: How has it changed since it was first noticed?
- Changed in the size.
- Changed in the color.
- Changed in the shape.
- Changed in nature.
Pain: Painful or Painless?
Is there any discharge?
If Yes, CCP ABC2O
- Character (Consistency). - Course (Frequency).
- Progression. - Amount.
- Blood\mucus. - Color\Content.
- Odor.
Aggravating and Reliving factors.
If suspicious of HERNIA then ask about:
- Irreducibility: was reducible then become irreducible, or any irreducibil-
ity in the past.
- Signs of obstruction: abdominal pain, distension, constipation and vom-
iting.
- Signs of strangulation: become irreducible, tender and sever pain.
191
History Taking of Any lump .. cont.
Abdominal pain, distension, constipation, vomiting, Heart burn, Change
bowel habit.
5. Risk factors for Hernias:

Age, Obesity, chronic cough, Injured muscles, Pregnancy and lifestyle (People
who have a job involving heavy physical labor are more prone to hernias due to
constant straining of the muscle and connective tissues).
#Ask about anything that can increase the intra-abdominal pressure

- COPD (due to cough)
- Benign prostatic hyperplasia (due to urinary obstruction)
- Ascites
#Ask about things that can cause weakness of the abdominal wall
• Smoking
• Age
• Steroid and any immunosuppressive medications
• Collagen disorder
• Surgical wounds (Previous surgeries)
#Ask about anything causes force application to tissues

1. Heavy lifting.
2.Obesity.
3.Constipation.
Fever (Documented or not), Night sweating, Loss of appetite, Loss of weight,
Fatigability.
8. Systemic review:
Check other systems and ask about any other symptoms in different system
whether related or not.
• DO you have : Chest pain , Dyspnea , Orthopnea, PND , Palpitations , Syncope
, Ankle swelling , Easy fatigue , Intermittent claudication , Cold extremities ,
Cyanosis ( CVS)
• DO you have : Wheeze , Cough , Sputum , Hemoptysis , Chest pain , Dyspnea
, Hoarseness of voice, Sore throat ( Respiratory)
• DO you have : Headache , Neck pain ,Visual disturbance , Seizures , Limb
weakness (CNS)
• DO you have : Dysuria , Hematuria , incontinence , polyuria (GU)
• DO you have : Joint pain , Bone pain , Anemia ( Hematology + Rheumatology )
• DO you have : Bruising, Itchiness ,Color changes, Rashes, Swelling ( Skin)
192
History Taking of Any lump .. cont.
9. Past medical history:

- Any known medical condition and chronic illness (DM and HTN…).
10. Past surgical history:

11.Drugs and Allergies:

-Any drug that the patient is using?
-Allergies to food, drugs, dust... etc.
12. Family history:

-Family history of similar condition.
-Chronic diseases in the family (DM and HTN…).
-Genetic diseases.
-Cancer.
13. Social history:

-Educational Level.
-Occupation.
-Smoking, alcohol, drug abuse.
14. Summary:
Patient’s ID, chronic illness, (known case of …), chief complain and duration,
important positive and negative symptoms.
Example:
Ahmad is 30 years old male known case of COPD presented to OPD with groin
swelling for 1 month.
The swelling was sudden in onset, reduced by the patient or by lying down,
bulging by lifting heavy object and cough, constant in size, shape and color,
there is no abdominal pain, distention, constipation, or vomiting.
15. Differential diagnosis:

According to the site: generally they are:
1-Breast Lump.
2-Neck Lump.
3-Abdominal Lump.
4- Groin Lump .
193
DDx of hernia :
inguinal Incisional Epigastric Periumbilical Femoral

-Low presenta-
-Caput medusa -Femoral her-
tion of inguinal -Chronic ab-
-metastatic nia
hernia scess
deposits from -Hydrocele of
-Femoral canal - Lipoma - Hematoma
intra-abdomi- the cord or ca-
lipoma. -Subcutaneous -Foreign body
nal tumor (Like nal of the neck
-Femoral lymph tissue growth granuloma
Sister Mary -un-descended
node -Deposit of
Joseph Nodule) testis-
-saphena varix tumer
-Umbilical -lipoma of the
-Femoral artery
granulomas cord
aneurysm
components of hernia:
Hernias are composed of a sac, the parts of which are described as the neck,
body and fundus and the hernial contents.
types of hernia:
Inguinal Hernias :
Inguinal hernias can be classified as “direct”
or “indirect”.
incisional Hernias:
A hernia that appears in the abdomen at the
site of a previous surgery.
Femoral Hernias:
Femoral hernias, along with inguinal hernias
are groin hernias
Umbilical Hernias:
Umbilical hernias occur near the bellybutton or navel,
Epigastric Hernias:
They occur due to a weakness, gap, or opening in the muscles or tendons of the
upper abdominal wall,
Hiatal Hernias (internal)
Hiatal hernias are slightly different from other types of hernias because they
are a weakness or opening in the diaphragm, which is the muscle that separates
the chest cavity from the abdominal cavity.
194
Inguinal canal walls:
A helpful mnemonic to remember inguinal canal walls include :
•MALT (2M, 2A, 2L, 2T)
Starting from superior, moving anticlockwise in order to posterior:
•Superior wall (roof): 2 Muscles
o internal oblique Muscle
o transverse abdominus Muscle
• Anterior wall: 2 Aponeuroses
o Aponeurosis of external oblique
o Aponeurosis of internal oblique
• Lower wall (floor): 2 Ligaments
o inguinal Ligament
o lacunar Ligament
• Posterior wall: 2 Ts
o Transversalis fascia
o conjoint Tendon
Femoral triangle boundaries :

• SAIL
This should be easy to remember because the femoral triangle is shaped
like a sail.
• Sartorius muscle (lateral border)
• Adductor longus muscle (medial border)
• Inguinal Ligament (superior border)
Hesselbach’s Triangle or Inguinal Triangle:

RIP:
R = lateral border of the rectus abdominis makes the medial border of the
triangle
I = Inferior epigastric vessels making the superolateral border of the triangle
P = Inguinal ligament (also called Poupart’s ligament)
This will help us remember that the direct inguinal hernia rip through the triangle
Complications :
Most hernias are uncomplicated at presentation. The three important compli-
cations of hernias are, in order of progression, irreducibility, obstruction and
strangulation.
These are:
Irreducibility : A hernia is ‘irreducible’ when the sac cannot be emptied com-
pletely of contents.
Obstruction : A hernia becomes obstructed when the neck is sufficiently narrow
to occlude the lumen of the intestine contained within the sac
Strangulation : Strangulation means that the blood supply of the contents has
ceased due to compression at the hernial orifice. 195
Causes of sudden or sustained increases in intra-abdominal pressure :
- Coughing
- Vomiting
- Straining during urination or defecation
- Pregnancy and childbirth
- Occupational heavy lifting or straining, and strenuous muscular exercise
- Obesity
- Ascites
- Continuous ambulatory peritoneal dialysis (CAPD)
- Gross organomegaly
196
Examination of the Lump and Hernia
1. [ WIPPER + ABCDEV]:
• Position for hernia: lying flat comfortably.
• Exposure: nipple to mid-thigh.
2. [ General examination]:
JACCOL
- Jaundice. Mnemonic for pal-
- Anemia. pation of a swelling:
- Cyanosis. Medical Students
Siting Exam Can Dive
- Clubbing. If Forget The Simple
- Odema. Things
- Lymphadenopathy.
3. [ Local Lump examination]:

A. Look:
Site, Size, Shape, Single or multiple, Color and texture of overlying
skin, Thickness, Discharge.
If the mass is suspected to be a hernia then ask the patient to stand
and observe if the mass disappears or not. Also, ask him to cough
and look.
B. Feel:
Temperature, Tenderness, Surface [regular, rough, irregular]and
Edge [Defined or indistinct].
C. Press for:
● Consistency: Hard, rubber, soft.
● Compressible: disappear on press and reappear on release.
● Reducible: disappear on press and reappear only with other force.
E.g. : inguinal hernia with cough.
● Fluctuation Test: Hold the swelling between your index and thumb
and then pressure using your other hand index to see whether the
swelling will push your index and thumb apart.
● Pulsatility: Place a finger from each hand on opposite sides of the
lump and feel,
- If they are pushed outwards and upwards: Expansile pulsation
- If they are pushed in the same direction (usually upwards): Transmit-
ted pulsation
● Fluid thrill in large fluid collection.
D. Percussion: Stony dullness for fluid, resonant for gas filled.
E. Move:
● Fixation to the skin.
● Mobility.
● Attachment to underlying structures.
F. Auscultate:
For bruits or bowel sound in case of hernia
197
G.Trans-illumination:
Light will pass through clear fluid not solid masses
- Done by using a bright pinpoint light source and a darkened room,
placing the light on one side of the lump and looking at the other
side if the light can be seen.
((+ve in water, plasma, serum, lymph or refractory fat)).
4. [General Examination]:
A: Regional lymph nodes
B: Surrounding tissue:
• Induration of surrounding tissues
• Any neurological deficit in surrounding tissues (sensory or motor)
• Any distal effects on limbs (swelling, edema, atrophy)
C: Quick general exam to the related system.
- Be sure to cover the patient and thank them at the end of the ex-
amination.
5. [Hernia Examination]:
• Start with WIPPER + ABCEDV
• Local Examination:
- If the patient was lying in bed start examination in this position
once you suspected a lump to be hernia ask the patient to stand up
(this allow hernia contents to fill the hernia sac).
- Always examine both sides.
● On standing position:
A)Inspect from the front:
1. Site (femoral, inguinal, abdominal).
2. Shape
3. Extended to scrotum or not.
4. Other scrotal swelling
5. Other swelling at any site of body.
B) Feel from the front:
Examine the scrotum; to decide if it’s scrotal or not; by examining its up-
per edge by your Thumb and index finger:
- If you can’t feel the upper limit so its most likely to be hernia
- if you can get above it, it’s a scrotal swelling not hernia.
- In children it could be encysted hydrocele of the cord “but it’s rare”.
C) Feel from the side:
If you make a provisional diagnosis of inguinal hernia then examine the lump it
self, stand at the side of the patient, place on hand at the patient’s back and
your examining hand over the swelling; you must determine the character of the
lump:
1.site, shape, size.
2.Temp.
3.Tenderness.
4. Fluctuation.
5.Composition (solid, fluid, gaseous).
198
D) Expansile cough impulse: “important feature”
While you are feeling the lump Ask patient to turn his head to the
other side and cough, if notice the swelling become tense and ex-
pands with coughing so it has cough impulse.
- Note that: absence of cough impulse doesn’t exclude hernia
E) Reducibility: “important feature”
When the contents of hernia return back to their normal anatomical
place.
● It is examined when the patient in supine position, Ask the patient
to reduce the hernia by himself.
● Press firmly to reduce the tension of the swelling, then gently com-
press the lower part of the lump, as the lump gets softer lift it up
towards the external ring.
● Once it all has passed slide your finger upward and laterally to-
wards internal ring to see if hernia can be controlled or not.
F) Controlled or not:
● While hernia is still reduced place two fingers over the Deep ingui-
nal
ring, ask patient to cough to see if the hernia is controlled or not
[Deep inguinal ring: Halfway between pubic tubercle and ant. Sup.
Iliac supine]
- controlled: indirect hernia
- not controlled: direct hernia
G) remove your hand and observe for reappearance of hernia:
● Indirect hernia: slide obliquely along the inguinal canal downward
& medially
● Direct hernia: project directly forward through the external ingui-
nal ring.
H) Percuss and auscultate the lump:
● If there is gut in the sac [resonant on percussion & audible bowel
sounds].
I) Examine the other side especially inguinal region:
[as inguinal hernias are bilateral]
● Ask patient to cough (to see if there is cough impulse at the other
side).
J) Examine scrotal contents of each sides.
6. [To complete my Examination]:

1- Do complete abdominal examination and look for other abdominal
hernias.
2- CVS & resp. Examination.
199
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Ulcer \ diabetic foot chapter
Abdulrahman Ali Shata
Abduleilah hassn Alluhaibi
Abdulrahman Mansour AL-temimi
Abdulaziz Samer Hazzazi
Revised by:
202
Ulcer\Diabetic foot history
1- Personal data:
Name, age, nationality, gender, time of admission , route of admission (
through OPD or ER )
2- Chief complain :
ulcer ,Its duration (minutes/hours/days/months/years).
3- HPI :
First symptoms
How did he notice it ?
Progression
How is it changed since it was first noticed ?
Persistence
Has it ever disappeared or healed ?
Multiplicity
Is there any other ulcer ?
Cause
What do you think is the cause of it ?
Pain
Is’t painful or not?
Is it associated with pain ? if yes (SOCRATES)
Are there any discharge? Claudication ? Fever ? Swelling ? Skin redness.
Pigmentation , Difficulty with walking.
5- Risk factor:
Diabetes (take a detail history of diabetes if he diabetic including the dura-
tion, past and present treatment).
Smoking.
Trauma.
Tight fitting shoes.
Bare walking.
Inappropriate chiropody.
Poor hygiene.
Fever.
Night sweat.
Loss of appetite (anorexia).
Loss of weght.
Fatigability.
203
Ulcer\Diabetic foot history .. cont
7- Systemic review:
CNS: Headache, numbness or weakness in the limbs, visual problems.
CVS: dyspnea, chest pain, palpitation, PND, cyanosis, syncope, Lower limb ede-
ma.
Urinary system: frequency, dysuria, hematuria, notarial, incontinence.

Musculoskeletal system: pain, swelling, deformity and limitation of joint move-
ment.
Respiratory: chest pain, dyspnea, runny nose, hemoptysis, wheeze, stridor.
GIT: vomiting, diarrhea, pain, distension, constipation, jaundice.
8- Past medical history :

-Any chronic diseases? (mention the related diseases for the chief complaint)
9- Past surgical history:

-Amputations and recurrent abscesses ?
-Any blood transfusion?.
10- Drug and Allergy history:

-Any drug that the patient is using? (mention the relevant)
11- Family history:

-Any similar condition in his/her family.
-Any Chronic diseases in the family
-Any Genetic diseases (mention examples if relevant(
12- Social history:

-Educational Level
-Occupation
And if related, ask about:, Sexual contact, Pets, Diet and Physical activity.
204
Example case history
Mr. Y 40 year old Saudi male patient known case of diabetes and HTN admitted through
ER 3 day ago Complaining of an ulcer in his right feet for one week , The ulcer was in
his right foot on the planter aspect of the second toe, He noticed the ulcer one week
ago, it is associated with mild offensive discharge red In color, but it is not associat-
ed with pain, unprogressive, he does not have another ulcer, he has a negative history
for ulcers, he don’t know the cause of it
He is diabetic for 7 year, he was on oral hypoglycemic for 2 year then he has been
shifted to insulin. He has no other risk factor
The ulcer is associated with decrease in sensation and discharge
There were no Constitutional symptoms
Systemic review Was Unremarkable
About his past medical Hx he is diabetic, hypertensive for 5 year, he has never be ad-
mitted for a similar or different reason, he has no Central nervous vascular accident
or transient ischemic attack or stable/unstable angina or MI Renal impairment/failure
or Eye problems,
he has no allergy for food or drugs
He has never done any surgical procedure before
There was no previous similar condition in his family.

His mother is diabetic and hypertensive
He is nonsmoker, teacher, he is married
13- Deferential diagnosis of ulcer :

Type of ulcer Causes Underlying diseases
Superficial venous insufficiency Varicose veins
Venous
Deep vein insufficiency Previous DVT
Atheroma
Large vessel disease (ischemia) Burger’s disease
Arterial
Small vessel disease (vasculitis) Rheumatoid arthritis
Polyarthritis nodosa
Alcohol
Diabetes mellitus
Neuropathic /Trophic
Tabes dorsalis
Traumatic Syrinomyelia
Bedsores
Others
Self-inflicted injury
Pyogenic organism
Often associated with
Infective Tertiary syphilis
Malnutrition
Mycobacterium ulcerans
Squamous cell carcinoma
Primary neoplasm
Neoplastic Basal cell carcinoma
Secondary neoplasm
Malignant melanoma
205
Ulcer Ex.
WIPPPER:
•Wash Your Hands.
•Permission.
•Privacy.
•Position.
•Exposure.
ABCDEV:
1. first examine the normal foot.
2. any Amputation.
3. any deformity of toes (hummer toe or hallux valgus).
4. fungal infection between the toes (“tinea pedis”).
5. Nails abnormalities (color, crack “chronic ischemia”, thickening of skin “neu-
ropathy”, hygiene and ulcers).
6. ischemic leg (shiny thin skin).
7. any signs of infection.
8. loss of hair distribution due to neuropathy.
9. muscle wasting (loss arch of foot).
10. Signs of DM [wrinkle skin, pigmentation].
11. Rise the foot and inspect for any deformity (Charcot foot)
206
Local Examination
- Inspection :
1. Number of lesion: single ulcer or multiple ulcers.
2. Site: describe in anatomical terms or measure the distance from the nearest
bony prominence.
3. Size: measure the dimensions with tape. Size must be measured in at least
two directions.
4. Shape: if the ulcer has irregular shape, draw it and add the dimensions.
5. Margin: any skin changes around the ulcer.
6. Base: on which the ulcer rests (bone, soft tissue…).
7. floor: the visible area that you are looking at.
a. granulation tissue: red sheet of delicate capillary loops, collagen,
bacteria, inflammatory cells and fibroblast covered by a thin layer of
fibrin or plasma indicate healing ulcer.
b. dead tissue: called slough when it separated it may expose the
healthy tissue.
c. scab: slough and small amount of discharge dry to become a scab.
8. Color:
a. solid brown or grey dead tissue indicate full thickness skin death
b. slough that looks like a yellow grey wash leather indicate syphilitic
ulcer.
c. Base of bluish unhealthy granulation tissue indicate tuberculous
ulcer.
9.Edge: there are 5 types of edge.
a.Sloping edge; this is healing ulcer and usually indicate venous ulcer.
Have a new skin growing around the ulcer edge, which is pale pink and
transparent.
b.Punched out edge; most often seen in the foot where pressure oc-
curred on an insensitive piece of skin. E.G. syphilis, trophic, diabetic,
leprosy and ischemic.
c.Undermined edge; it seen in tuberculous ulcer.
d. Rolled edge; it develops when there is a slow growth of tissue in the
edge of ulcer and it’s typically
seen in basal cell carcinoma
(Rodent ulcer).
e. Everted edge; when there is
rapid growth of the tissue in the
edge of ulcer and spills out of the
ulcer to overlap the normal skin.
It’s seen in squamous cell
carcinoma
10.Depth: measure it in millimeters and
anatomically
by describing the structures it has
penetrated.
11.Discharge: blood, pus or serous. 207
- Palpation :
(always ask if the ulcer is painful or tender)
1.Ulcer: (feel the ulcer with gloves)
• Size
•Edge (press on edges to see if there is discharge)
o Soft: healing
o Firm: non-healing
o Hard: malignant
•Depth
• Discharge
•Temperature: asses the temperature by the dorsal surface of your fin-
gers.
• Tenderness
• Base (Ask pt. to move his toes bone, muscle or tendon may appear)
• Floor : Granulation tissue, Blood, slough, discharge
2. Surrounding Skin:
•Tenderness
•Temperature: assess the temperature by the dorsal surfaces of your fin-
gers.
(You should always compare between both Legs)
3. Examination of the surrounding tissues

•Induration: thickening of edge in response to inflammation, trauma,
chronic infection, and malignancy.
•Scarring: From previous ulcer.
• Pigmentation: Commonly around venous ulcer.
• Edema:
o Local cause: obstruction of venous or lymphatic system.
o General cause: liver, renal, cardiac failure, and hypoalbuminemia.
•Fixation to deep structure: To know if the ulcer adherent or invading
deep structures such as tendons, periosteum, and bones.
•Vascular assessment:
oCapillary Refilling: press on the tip of nail or the pulp of a toe for
2 sec, then observe the time taking to return pink normal Capillary
refill time within 2-3 sec.
oPulses by palpation. see page {} (Lower limb pulses)
•Regional lymph nodes:
o Inguinal L.N (assess the local LN at site of the ulcer)
o The lymph node should be examined in DSF is popliteal and femo-
ral.
•Neurological Exam:
o Test sensation of the surrounding tissues: (Light touch, pin prick,
temperature, proprioception and vibration).
oPower and movement of related muscles and joint.
At the end of your examination, ask the patient to cover the exposed area
208 and thank them.
Difference Between Ischemic and Neuropathic Ulcers
Ischemic ulcer Neuropathic ulcer
Painful Painless
Black eschar present Black eschar absent
Cold surrounding area Warm surrounding area
Sensation intact Sensation lost
Peripheral pulses examination, Both upper limb

1.Radial artery :
•The pulse is usually felt just medial to the
radius, using the forefinger and middle finger
pulps of the examining hand wrist.
• To assess rate and rhythm.
• Simultaneously with femoral to detect delay
2. Brachial artery:
• Medial border of humerus at elbow medial to biceps tendon.
• Either with thumb of examiner’s right hand or index and middle of left
hand.
• To assess pulse character and to confirm the rhythm.
Both lower limb

1.Femoral artery :
• Patient should be lying flat and undressed.
• Place finger directly above pubic ramus and midway between pubic tu-
bercle and anterior superior iliac spine.
• To assess cardiac output.
• To detect radio femoral delay.
• To assess peripheral vascular disease.
2.Popliteal artery:
• Deep within the popliteal fossa.
• 3 techniques :
A.extend the patient’s knee fully and place both hands around the top of
the calf, with the thumbs placed on the tibial tuberosity and the tips of
the fingers of each hand touching behind the knee, over the lower part of
the popliteal fossa. The pulps of all the fingers are then pulled forwards
against the posterior part of the tibial condyle, trapping the popliteal
artery between them and the posterior surface of the tibia.
B.Flexing the knee to 135° loosens the deep fascia and may make the
lower half of the artery easier to feel. The vessel is, however, moved fur-
ther from the surface by bending the knee, and this may make palpation
of the upper half of the artery more difficult as it sinks into the large fat
pad between the femoral condyles. 209
`C. turning the patient into the prone position and feeling along the course
of the artery with the fingertips of both hands.
• Mainly to assess peripheral vascular disease In diabetic patients.
3. Dorsalis pedis artery :

•Anterior surface of the ankle joint, Towards the cleft
between the 1st and 2ed metatarsal bones.
•Mainly to assess peripheral vascular disease In
diabetic patients.
4. Tibialis posterior artery:

•Posterior to medial malleolus.
210
Neck mass and thyroid chapter
Alaa Mohammed Khayyat
Nada Abdulrahman Temesani
Sumaya Ahmad Fallata
Ebtsam Mohammad Alhothali
Revised by:
Anmar Mohammed Batawi
212
History of Neck Mass
1-Personal Data:
2-Chief Complaint
a) Neck mass/ lump,
b) Compressional Symptoms &
c) Symptoms of Hyper- or Hypothyrodism.
And its duration.
3-History of Presenting Illness:

Site: Where Is the Lump?
First symptoms: How Did You Notice It? (Noticed Accidently, Told by Other,
Painful).
Duration: When Did You Notice It?
Persistence: Has It Ever Disappear? How and What Does Make It Disappear?
Progression: Any Change In (Size, Color, Shape) Since You First Notice It?
Pain: Is It Painful? (Socrates)? or Painless?
Relieving: Have You Taken Anything to Treat It?
Cause: What Do You Think the Cause? (Trauma? Surgery?) Any Use of Treat-
ment?
Other symptoms: Is There Any Discharge? (Spontaneous Oozing or On Pres-
sure), Amount, Color, Bloody and Consistency?
Multiplicity: Another Lump at Any Other Site or Same Site?
Recurrence: Any Previous History of Lump?
How Does the Lump Disturb You?
Discharge, Pressure Symptoms
{Pain, Difficulty in Swallowing (Dysphagia) Or Breathing(Dyspnea), Voice
Change(Hoarsness)}.
5-Risk Factor:
Related to Thyroid:
a) Hx Of Thyroid Cancer or Thyroid Problem.
b) Hx Of Radiation or Treatment with Radioactive iodine.
c) Family history of thyroid Cancer OR MEN syndrome associated condi-
tions.
# Related to Lymphadenopathy:
a) Hx Of Mouth Ulcer.
b) Hx Of Infection as TB.
c) Contact with Infected Person.
d) Immunization: BCG.
e) Smoking / Alcohol.
f) Surgery/ Trauma. 213
History of Neck Mass .. cont.
6-Constitutional Symptom:
B Symptoms (Fever, Fatigue, Weight Loss, Night Sweating.)
7-Systmic Review:
[ Full Systemic Review With More Concentration On The Symptoms Related To
Thyrotoxicosis, Hypothyroidism, And Lymphadenopathy]
Regarding Thyroid :
- General: Weight Increased/Loss, Appetite Loss/Increased, Irritability,
Menstrual Cycle Change.
- CNS: Seizure, Headache, Nervousness, Drowsiness, Weakness, Psychosis
(Depression and Excitement) Abnormal Movement.
- CVS: Palpitation, Chest Pain, Dyspnea, Orthopnea, Intermittent claudi-
cation, Syncope, Lower Limb Edema.
- GIT: Diarrhea, Constipation, Jaundice, Vomiting, Pain.
- Eyes: Double Vision (Ophthalmolagia), Painful Red Eye, Difficulty Closing
the Eye (Exophthalmos), Protrusion of The Eye (Proptosis), and Swelling
of The Conjunctiva (Chemosis).
- Skin: Intolerance to Cold or Hot, Dry Skin.
Regarding Lymphadenopathy:
- Throat: Sore Throat, Voice Change, Difficulty Swallowing, Ulcer in
Mouth, Scalp or Face, Ear and Nasal Discharge.
8-Past Medical Hx:

- Any Previous History of Similar Attack?
- Any Chronic Diseases?
- Previous Hospitalization (Why?)
9-Past Surgical:
- Any Previous Operations? (Type, When, Complications, Outcome)
- Any Blood Transfusion?
10-Drug and Allergy Hx:

- Any Drug That the Patient Is Using?
- Allergies to Food, Drugs, Dust. Etc
11-Family Hx:
- Similar Illness (thyroid problem or cancer. Hx of infection e.g. TB)?
- Chronic Diseases in The Family?
- Genetic disease?
- Cancer?
214
History of Neck Mass .. cont.
12-Social Hx:
- Marital Status? And If There Are Any Children?
- Educational Level?
- Occupation?
-Smoking: Passive or Active? Which Type? Duration?
- No. Of Packs Per Day Then Calculate It in Pack-Year
- If Ex-Smoker (For How Long?)
- Alcohol & Drug Abuse?
- And If Related, Ask About: Sexual Contact, Pets, Diet and Physical Activity
13-Summary:
A 44-year-old female known case of hypertension compliance to her medica-
tion presented with a five-month history of an anterior neck swelling which
fluctuated in size. She complained only of fatigue, with no symptoms of thy-
roid or parathyroid dysfunction or local compressive symptoms.
13- Differential diagnosis (DDx.) :

Differential Diagnosis of Neck Swelling in General
Midline Neck Swellings
1-Throid Swelling
-Diffuse Swelling.
Common -Multinodular.
-Solitary Nodule.
2-Thyroglossal Cyst(Congenital).
1-Lymph Node (Infectious or Neoplastic).
2-Sublingual Dermoid Cyst (Congenital).
Uncommon 3-Plunging Ranula.
4-Subhyoid Bursa.
5-Carcinoma of Larynx/Trachea/Esophagus.
Lateral Neck Swellings
Posterior Triangle Anterior Triangle
1-Lymph Node. 1-Lymph Node.
Lymph Nodes
2-Cold Abscess. 2-Cold Abscess.
1-Submandibular Swelling.
Salivary Gland ---
2-Parotid Gland Swelling.
1-Cystic Hygroma.
Cystic Structures 1-Branchial Cyst
2-Pharyngeal Pouch.
1-Carotid Body Tumor. 1-Subclavian Artery Aneu-
Vascular Structures
2-Carotid Artery Aneurysm. rysm.
215
Neck mass Examination
WIPPPER:
•Wash Your Hands.
•Permission.
•Privacy.
•Position.
•Exposure.
ABCDEV:
• Facial asymmetry: (sternomastoid tumor in neonate)
• Hand:
Pseudo-clubbing, Cyanosis, Sweat/Moist, Palmar erythema, Skin Tempera-
ture, muscles wasting, puffy hand and Fine tremor.
•Eye:
-Eye movement: Squint (sternomastoid Tumor in neonate)
-Lid retraction: Normally the upper part and lower part of iris covered by
upper and lower lids, in patient with lid retraction will see the iris not cov-
ered and sclera around it totally visible.
-Lid lag: Ask the patient to follow your finger while moving your finger
downward more than once, and notice the upper lid while your moving.
normally will you notice the upper part of iris is covered by upper lid, in
patient with lid lag the upper part of iris will be not covered.
216
–Exophthalmos: try to notice if there is any protrusion of eyeballs by
looking from above of the patient head.
-Ophthalmoplegia (Diplopia)
-Chemosis: try to notice if there is any edema (swelling) of the conjuncti-
va
• Ear
•Nose: mass and discharge
Local Examination:
- Inspection:
From in front of the patient is there any:
• Scars (previous Excision)
• Masses: If there is mass confirm by:
o 4S: Site, size, shape and skin changes (sign of inflammation).
o Number
o Relation to:
- Muscle (fixed when the muscle contraction)
- Trachea: by asking the patient to swallow and observe, if the
mass move with swallowing or not (use water or something).
- Hyoid bone: by asking the patient to protruded his/her tongue
and observe if the mass move or not (Thyroglossal cyst).
o Distended neck veins
o Laryngeal prominence position: central or not
o Sinus with/without discharge
o Sign of trauma (laceration, abrasion, bruise)
Look to all aspect of the neck including back of the neck for C-supine defor-
mity/swelling in trauma.
- Palpation:
• Examine the trachea and do tracheal tug (it maybe You must know
the triangles of
compressed or deviated to one side due to retrosternal the neck
goiter)
• Examine:
From behind of patient:
o Lymph node: sub-mental, lingual, submandibular,
anterior/posterior cervical, pre/post auricular,
Thyroid gland
occipital and supraclavicular lymph nodes. attaches to tra-
chea and larynx
through pre-tra-
cheal fascia
217
o parotid gland
o Thyroid:
Ask the patient to swallow and do thyroid examination and protruded his/
her tongue, if there is midline thyroid mass do thyroid examination (see
thyroid examination)
o Lump (Masses), Comment on:

- Size
- Shape
- Edges (well define or irregular)
- Surface (smooth or irregular)
- Skin changes (erythema, punctum)
- Tenderness
- Consistency (soft, rubbery, hard and stony hard)
- Temperature (infective lesion)
- Fluctuation (fluid filled lesion)
- Related to muscle (tethered or mobile)

(N.B: superficial mass palpable and prominent during relaxation and con-
traction of the muscle but deep mass become impalpable during contrac-
tion)
- Pulsatility and thrill (vascular etiology)
- Compressibility and reducibility.
• Repeat in front of the patient :

- Percussion:
Dullness (Solid), Fluctuant (Fluid)
- Auscultation:
Bruit (vascular etiology)
To complete your examination:

• Systemic examination (CVS, Respiratory, GU, GI ...)
• Radiology
• Fine needle aspiration (FNA)
218
Neck Triangles:
To confirm triangles of the neck should ask the patient to:
A- Put your hand under the chin of the patient and ask him to move his head
against your hand (contraction of sternocleidomastoid muscle)
B- Ask the patient to elevate his/her shoulder against your hand (trapezius
muscle)
Triangles of the neck:
219
Thyroid Examination
WIPPPER:
•Wash Your Hands.
•Permission.
•Privacy.
•Position.
•Exposure.
ABCDEV:
- General Examination:
Hyperthyroidism Hypothyroidism
- Looks lethargic and ap-
athy.
- Looking nervous and worried.
- Overweight with exces-
- Thin, wasting of muscles.
General Appearance sive fat deposition.
- Looks hot and sweaty (intolerance to heat).
- Intolerance to cold.
- Constant movement of the hands and fingers.
- Enlarged tongue with
deep and hoarse voice.
- Nail clubbing (Thyroid aeropathy).
- Onycholysis (separation of nail from its nail
bed).
- Cold, dry and swollen
- Sweating/moist and wasting of small mus-
hands.
cles.
- Peripheral cyanosis.
Hands - Palmar erythema.
- Pale hand (anemic).
- Tachycardia.
- Bradycardia.
- Irregular pulse.
- Low pulse volume.
- Fine tremor of the outstretched hands (lay-
ing a sheet of paper over the patient fingers
may more clearly demonstrate these tremors).
220
cont. :
- Lid retraction (upward displacement of the up-
per eyelid or downward displacement of the lower
eyelid thereby exposing the sclera).
- Lid lag (delay in moving the eyelid as the eye
moves downwards, known as Graefe’s sign): ask
the patient to follow your finger while you are
- Swollen and heavy
moving it downward more than once and notice
eyelids (sleepy and le-
the upper lid while you’re moving; normally, you
thargic appearance).
Eyes will notice the upper part of the iris is covered by
- Loss of hair in the out-
the upper lid. But, in the patient, the upper part
er third of eyebrow.
of the iris will be not covered.
- Exophthalmos (abnormal protrusion of the eye-
ball) by looking from above of the patient’s head.
-Ophthalmoplegia (paralysis of the muscles within
or surrounding the eye).
- Chemosis (edema of the conjunctiva).
- Corneal ulceration.
A. Unilateral right lid retraction.

B. Lid lag on downward gaze on the right eye.
C. Proptosis (Exophthalmos).
221
- Local Examination (Neck):
- Inspection:
Observe from in front and from either side for:
- Normal thyroid maybe visible in thin young person.
- Hyperemia of the skin (which may indicate inflammation or infection).
- Scars, sinus, fistula and discharges.
- Distended neck veins (may indicate obstruction of the thoracic inlet due
to huge goiter with retrosternal extension).
- Look for skin puckering and pulled up by swelling which may indicate in-
filtrated thyroid cancer into the skin or previous thyroid surgery.
Then, ask the patient to:

- Swallow or take a sip of water to observe if the mass moves with swallow-
ing or not (goiter will move up with swallowing).
- protrude his/her tongue to observe if the mass moves with tongue protru-
sion (Thyroglossal cyst will move up with tongue protrusion).
If there is a mass, then confirm:

- 3Ss: Site, Size and Shape.
- Number.
- Color.
- Relations to trachea.
- Palpation:
a. From in front of the patient:
- Ask if the swelling is panful or not.
- Assess the size, shape, surface and tenderness of the swelling.
- Tracheal position: by feeling with tip of two fingers in the supra-ster-
nal notch, it may be deviated by huge goiter.
- Tracheal tug: downward pull of the trachea during inspiration.
b.From behind the patient:
- Move behind the patient and put both your hands gently around the
patient’s neck while your fingertips palpate over the gland. The pa-
tient’s neck should be slightly flexed to relax the sternomastoid mus-
cle.
- Feel systematically each side of the gland by supporting one side
and feeling the other and don’t forget to feel the isthmus in the cen-
ter.
- Ask the patient to swallow – while you palpate the mass – to check if
there is small nodular goiter and try to feel the lower border.
- Comment on the following:
• Size: Make sure to feel the lower border, if absence, may be a
retrosternal extension.
• Shape: Note whether the gland is uniformly enlarged, has only
a nodular enlargement, or has multiple nodules. If there is only a
nodular enlargement comment on its site, size, shape, consisten-
222
cy, tenderness and mobility.
• Tenderness: may suggests thyroiditis.
• Consistency:
- Soft: normal feeling of the gland.
- Firm: in simple goiter.
- Rubbery or Hard: in Hashimoto’s thyroiditis.
-Stony hard: in carcinoma, calcification in a cyst, fibrosis or Riedel’s
thyroiditis.
• Mobility: Carcinoma may tether the gland.
• Thrill: may be felt in thyrotoxicosis.
- Palpate cervical lymph nodes: may be involved in thyroid carcinoma.
- Palpate each carotid artery: absence of its pulsation may indicate compres-
sion by large goiter.
- Percussion:
On the sternum, to confirm retrosternal extension of the thyroid gland.
- Auscultation :
- Systolic bruit: over the lateral lobes; due to increased blood supply to the
gland that may occur in hyperthyroidism.
- Carotid bruit: due to compression of carotid artery by huge goiter.
- Venous hum: due to retrosternal extension of thyroid gland.
- Pemberton’s Sign: (for retrosternal extension) :

Ask the patient to left both arms as high as possible and wait few seconds
then observe for signs of thoracic inlet obstruction due to retrosternal goi-
ter. The signs include:
- Face Congestion.
- Cyanosis.
- Respiratory Distress.
- Inspiratory Stridor.
- Neck vain distention.
- To complete your examination: Don’t forget to cover the patient and thank them at the end of your examination.
- Dry, smooth, inelastic skin
Pretibial myxedema over the shins (in Graves’
Skin with non-pitting edema.
disease).
- Hair looks thin and fall out.
- Irregular pulse (extra-systoles and atrial fibrilla-
- Bradycardia.
tion).
- Low blood pressure.
CVS - Tachycardia at rest, which persist during sleep.
- Cold hands with peripheral
- Rales at the base of the lungs and ankle edema
cyanosis.
(indicate the onset of heart failure).
- Slow thought.
- Worried and nervous appearance. - Slow speech.
- Fine tremor. - Slow movements.
CNS - Constant movement of the hands and fingers. - Decrease power and sluggish
- Increase reflexes and power in proximal upper reflexes with prolonged relax-
and lower limbs. ation phase in proximal upper
and lower limbs. 223
In Summary: (most important points)
1- WIPPER.
2- ABCDEV.
3- General examination:
- General Appearance.
- Hands (Nails, Moist or Cold, Pulse and Fine tremor).
- Eyes (Lid lag, Lid retraction and Exophthalmos).
4- Local examination:
- Inspection (Skin changes, mass movement during swallowing and
protruding the tongue and describe size, site, shape, number, color of
the mass and its relation to trachea).
- Palpation (From in front: tracheal position and tracheal tug), (From
behind: palpate gently and comment about symmetry, size, shape,
tenderness, consistency, mobility and thrill) and palpate lymph nodes
and carotid artery.
- Precaution (On the sternum).
- Auscultation (For bruit and venues hum).
- Pemberton’s sign.
5- Complete your examination:

- Skin (Pretibial myxedema).
- CVS.
- CNS.
In Summary: (most important points) + Pictures

1- WIPPER.
2- ABCDEV.
3- General examination:
(Feel the pulse)
- General Appearance.
- Hands (Nails, Moist or Cold, Pulse and Fine tremor).
- Eyes (Lid lag, Lid retraction and Exophthalmos).
(Inspect for tremor in the

hands)
(Lid lag)
224
4- Local examination:
- Inspection (Skin changes, mass movement during swallowing and protruding
the tongue and describe size, site, shape, number, color of the mass and its
relation to trachea).
(Observe the neck) (Observe the neck as the

patient drinks)
-Palpation (From in front: tracheal position and tracheal tug), (From behind:
palpate gently and comment about symmetry, size, shape, tenderness, con-
sistency, mobility and thrill) and palpate lymph nodes and carotid artery.
(Palpate the thyroid (Palpate the cervical

gland) lymph nodes)
- Precaution
(On the sternum).
- Auscultation
(For bruit and venues hum).
- Pemberton’s sign.
- Complete your examination:

- Skin (Pretibial myxedema), CVS, CNS.
References:
- Clinical Surgical Skills – AlQahtani, Page: 54-62
- Clinical ABCs – By Batch 31, Page: 218-222
- Clinical ABCs for Surgery – By Batch 32, Page: 82-84
- Pictures: http://www.osceskills.com/e-learning/subjects/thyroid-examination/
And http://geekymedics.com/thyroid-status-examination 225
- Differential Diagnosis:
Differential Diagnosis of Thyroid Enlargement
a. Physiologic:
- Puberty
- Pregnancy
b. Inflammatory:
- Hashimoto’s thyroiditis
- De Quervain’s thyroiditis (Giant
1-Diffuse goiter:
cell thyroiditis)
c. Neoplastic:
- Lymphoma
- Anaplastic
d. Autoimmune:
- Graves’ disease
2-Multinodular goiter (MNG) ----
a. Dominant nodule in a MNG
b. Cystic (colloid cyst)
c. Solid:
• Benign: Adenoma
3-Solitary nodule:
• Malignant:
- Papillary carcinoma
- Follicular carcinoma
- Medullary carcinoma
Causes of Hyperthyroidism and Hypothyroidism

1- Graves’ disease: 1. Primary myxedema:
- Autoimmune - Autoimmune
- Younger patient - Older patient
- Diffusely enlarged thyroid - No goiter
1. Hashimoto’s thyroiditis:
- Autoimmune
1- Multinodular goiter (MNG): - Younger patient
- Old patient - Rubbery goiter
- At an early stage, patient may be hyper-
thyroid
1- Functioning adenoma:
1- Post-total thyroidectomy
- Rare
2- Post-radioiodine ablation
- Most are non-functioning
Thyroid Carcinoma:
References: - Papillary
- Clinical Surgical Skills – AlQahtani, Page: 61 (most popular).
- Follicular.
- Toronto Notes 2016 -Medullary.
- Anaplastic
(most dangerous).
- Lymphoma.
226
Lymph node Examination
WIPPPER:
•Wash Your Hands.
•Permission.
•Privacy.
•Position.
•Exposure.
ABCDEV:
Local inspection:
Identify any scars on the neck – previous surgery (e.g. thyroidectomy)
Observe for any obvious masses in the neck or lymphedema
Palpation
Lymph nodes can become enlarged for a number of reasons – infection / malig-
nancy
Character: Lymph nodes are usually smooth, rubbery, with some mobility.
An enlarged, hard, irregular lymph node would be suggestive of malignancy.
Technique:
Use the pads of the index and middle finger (The “flat” of the fingers not
the tip) to move the skin in circular motions over the underlying tissues in
each area; palpate both sides of the neck simultaneously.
small nodes (< size of distal phalanx of little fingure) are normal unless in
unusual location (pre-auricular).
Any abnormal nodes, describe in terms of:
Location
Size
Shape (regular vs irregular border)
Mobility (mobile vs fixed)
Tenderness (tender vs non-tender)
Texture (soft vs firm)
227
Be sure to examine the neck lymph nodes systemically and localize any
swelling or abnormalities to a group of lymph nodes as follow:
1. Sub-Mental: Just below the chin.
• Drainage: The teeth and intra-oral cavity.
2. Sub-Mandibular: Along the underside of the jaw on either side.
• Drainage: The structures in the floor of the mouth.
3. Preauricular: in front of the tragus of the ear.
4. Postaurricular: behind the ear.
5. Occipital: in the occipital region of the head.
6. Anterior Cervical (both superficial and deep): Nodes that lie both on
top of and beneath the sternocleidomastoid muscles (SCM) on either side
of the neck, from the angle of the jaw to the top of the clavicle. This
muscle allows the head to turn to the right and left. The right SCM turns
the head to the left and vice versa. They can be easily identified by ask-
ing the patient to turn their head into your hand while you provide resis-
tance.
• Drainage: The internal structures of the throat as well as part of
the posterior pharynx, tonsils, and thyroid gland.
7. Posterior Cervical: Extend in a line posterior to the SCMs but in front
of the trapezius, from the level of the mastoid bone to the clavicle.
• Drainage: The skin on the back of the head. Also frequently en-
larged during upper respiratory infections (e.g. mononucleosis).
8. Supra-clavicular: In the hollow above the clavicle, just lateral to
where it joins the sternum.
• Drainage: Part of the thoracic cavity, abdomen.
The left Supra-cla-

vicular lymph node
(Virchow’s node) has
special importance as
its enlargement indicate
abdominal malignan-
cies. (Troisier’s sign)
reference : A Practical Guide to Clinical Medicine

Copyright ©2015, The Regents of the University
of California.
All rights reserved. Last updated 10/15.
228
Breast chapter
Rawabi Ahmed Barnawi
Alhanoof Gamal Bokhary
Revised by:
Asya Rezayq alsulami
230
History of Breast Mass
[Don’t forget to introduce yourself & take permission from the patient.]
1- Personal data :
Name, age, sex , nationality , time & route of admission (Through OPD or ER)
2- Chief complain & the duration :

Breast mass, Ask about the duration of symptoms (minutes /days /moths /
years)
3-History of present illness:

●Onset:
When did you first notice the lump ?
●First symptom:
How did you notice it ?
●Progression:
Did it change since you notice it ?
● Pain:
Is it painful ?
●Course:
Dose the lump ever disappear ? what makes the lump to reappear ?
●Multiplicity:
is there another [multiple] breast lump ?
● Discharge:
is there any discharge from the nipple ? if yes, ask :
- is it from one or both nipples ?
- volume ?
- color ?
- consistency ?
- smell ?
- is it milky or bloody ?
- Recent history of breast feeding ?
4. Associated symptoms :
● Metastasis:
is there any axillary lump ?
● Hormonal effect:
is there any cyclical variations[increase in size before menses & decrease
after menses]
● skin change:
is there any redness? Ulceration?
5- risk factors :
● Trauma:
is there any history of trauma ?
231
History of Breast Mass .. cont.
● Past Hx:
Did you have any previous breast lump ?
● Family history:
has anyone in your family had breast lump or breast cancer?
● Hormonal effect;
Is she using any exogenous hormones ?
- Oral contraceptive pills ?
- Hormonal therapy ?
is there any mental change ?
Is there bone pain ?( low back pain )
Is there any nodule in the skin of the breast ?
● Gynecological history:
How many children does she have ?
Age of first full term pregnancy ?
Previous pregnancies ?
- How many ?
- When ?
- Type of delivery ?
- Are they breastfed ?
Fever, Fatigue, Weight Loss, Loss of Appetite and Night Sweating.
7. Systemic Review :
You should ask all the systemic review symptoms BUT this is the most import-
ant Qs you shouldn’t forget because they are indication of:
● metastasis :
- General malaise, weight loss ?
- Mental changes ?
seizures ? (brain metastases)
- Jaundice ? (Liver metastases)
- Dyspnea, pleuritic pain? (respiratory metastases)
- Bone pain
- Nodules in the skin ?
● Menstrual History :
• Age of menarche :
How old were you when you had your first period ?
• Age of menopause:
How old were you when you had your period stopped ?
• menstrual cycle :
What is the menstrual pattern ? (Regularity, duration, quantity
of bleeding)
• Breast symptoms with menstrual cycle ?
232
Other system:
-DO you have : (Chest pain, Dyspnea, Orthopnea, PND, Palpitations, Syncope,
Ankle swelling, Easy fatigue, Intermittent claudication, Cold extremities, Cya-
nosis) (CVS)
- DO you have : ( Wheeze, Cough, Sputum, Hemoptysis, Chest pain, Dyspnea,
Hoarseness of voice, Sore throat ) (Respiratory)
- DO you have : (Vomiting, Nausea, Heart burn, Abdominal pain, Change bowel
habit) (GIT)
- DO you have :( Headache, Neck pain, Visual disturbance, Seizures, Limb weak-
ness) (CNS)
- DO you have :( Dysuria, Hematuria, incontinence, polyuria ) (GU)
- DO you have :( Joint pain, Bone pain, Anemia ) ( Hematology + Rheumatology )
- DO you have :( Bruising, Itchiness, Color changes, Rashes, Swelling) ( Skin)
8. Past medical :
• Have you had breast or ovarian cancer before ? others cancers ?
• Trauma to the breast ? (Traumatic fat necrosis)
• Do you have any chronic diseases ?
9- surgical history :
• Previous procedure in the breast like biobsy or lumpectomy ?
• Any Blood transfusion.?
10- Drug & allergic history :

• Do you take any medications ? or have you taken any recently ?
• Do you have any known allergies to Food, Drugs, Dust. Etc
11- Family history :

• Family history of similar symptoms ( Has anyone in your family had breast
lump ?)
• Has anyone in your family had breast or ovarian cancer ?
blood diseases)
12- Social history :

- Educational level
- Occupation
- Smoking : either passive or active ( ask about type , duration, no of packs
per day then calculate it in pack - year ) or Ex – smoker ( for how long?)
- Alcohol &Drug Abuse 233
- Sexual contact
13-DDx :
If it is painful lump :
- breast abscess
- fibroadenosis
- inflammatory breast cancer
- costal cartilage chondritis
if it is painless lump :
- carcinoma
Breast mass - fibroadenoma
- trauma fat necrosis
- duct papilloma
if it is massive enlargement :
- benign hypertrophy
- giant fibroadenoma
- phylloides tumor
- colloid carcinoma
234
History of Breast Pain
[Don’t forget to introduce yourself & take permission from the patient]
1- Personal data
Name, age, sex, nationality , time & route of admission (Through OPD or ER).
2. Chief complain & the duration :

Breast pain, Ask about the duration of symptoms (minutes/days/months/
years).
3. History of present illness : (SOCRATES)

● Site :
Where is the pain ?
● Onset :
Did it start suddenly or gradually ?
● Character :
What is the nature of the pain ?
● Is the pain unilateral or bilateral ?
● Radiation :
Is the pain radiating or shifting to another place ?
● Aggravating and relieving factors :
Is there any aggravating or relieving the pain ?
●Time Course:
Is the pain continues or intermittent ?
If it is intermittent ask about :
- How many attacks does she have ?
- What is the time between each attack ?
- For how long each attack persists ?
● Severity:
does it affecting your daily life, work or sleeping ?
● Progression :
Is the pain getting worse or not ?
4. Associated Symptoms :
● Is there any nodule in the skin of the breast ?
●Hormonal effect:
Is the pain cyclical or acyclical ?( change with menses or not )
● Metastasis:
● skin change:
is there any redness? Ulceration?
● Discharge:
is there any discharge from the nipple ? if yes, ask :
- is it from one or both nipples ?
- volume ?
- color ? 235
History of Breast Pain .. cont.
- consistency ?
- smell ?
- is it milky or bloody ?
- Recent history of breast feeding ?
5- risk factors :
● Trauma:
● Past Hx:
Did you have any previous breast pain ?
● Family history:
- How many ?
- When ?
- Are they breastfed ?
6. Constitutional Symptoms :
7.Systemic Review :
● Metastasis :
-Mental changes ?
- seizures ? (brain metastases)
- Bone pain
• Age of menarche :
236
What is the menstrual pattern ? (Regularity, duration, quantity of bleeding)
Other system:
- DO you have : (Chest pain, Dyspnea, Orthopnea, PND, Palpitations, Synco-
pe, Ankle swelling, Easy fatigue, Intermittent claudication, Cold extremities,
Cyanosis) (CVS)
- DO you have : ( Wheeze, Cough, Sputum, Hemoptysis, Chest pain, Dyspnea,
- DO you have : (Vomiting, Nausea, Heart burn, Abdominal pain, Change bowel
habit) (GIT)
- DO you have :( Headache, Neck pain,Visual disturbance, Seizures, Limb
weakness) (CNS)
- DO you have :( Dysuria, Hematuria, incontinence, polyuria ) (GU)
- DO you have :( Joint pain, Bone pain, Anemia ) ( Hematology + Rheumatolo-
gy )
- DO you have :( Bruising, Itchiness, Color changes, Rashes, Swelling) ( Skin)
8.Past medical :
9- Past surgical history :

10. Drug & allergic history :

• Do you take any medications ? (oral contraceptive pills)
11- Family history :

pain ?)
• chronic disease ?
• Genetic diseases?
237
12. Social history :
- Educational level
- Occupation
- Sexual contact
13- Summary :
ID, Chief complaint, Duration, HPI, Chronic disease, Positive symptoms in sys-
temic review & Negative .
A 50 years old female patient, compliance of breast pain unilateral on left side
about 2 month ago, The pain is localized, burning, continuous, but no discharge
, redness or radiating.
She has DM and HT .
14- DDx :
Cyclical breast pain ( related to the menstruation )
Breast pain
Acyclical breast pain\ Carcinoma ( rarely )
238
History of Nipple Discharge
1. Personal Data :
Name, age, sex, nationality, time & route of admission (Through OPD or ER).
2. Chief Complain &duration :

nipple discharge, Ask about the duration of symptoms (minutes /days /moths
/ years)
3. History of Present Illness :

● Is the discharge from one or both nipple ? Which side?
● Frequency
● volume:
The volume of nipple discharges
● color:
What color is the discharge? Blood stained? [single duct blood stained
nipple discharge may be the result of duct papilloma or carcinoma]or
galactorrhea[milky]
● Associated symptoms :
● Metastasis :
● Hormonal effect :
is there any cyclical variations[increase in size before menses & de-
crease after menses]
● skin change:
is there any redness? Ulceration ?
● breast pain ?
● breast lump ?
4. Risk factor :
● Trauma :
● Recent history of breast feeding?
● Past Hx:
Did you have any previous breast lump ?
● Family history:
239
History of Nipple Discharge .. cont.
- How many ?
- When ?
Are they breastfed ?
6. Constitutional Symptoms :
7. Systemic review:
You should ask all the systemic review symptoms BUT this is the most import-
ant Qs you shouldn’t forget because they are indication of:
● metastasis :
- Mental changes ?
- seizures ? (brain metastases)
- Bone pain
•Age of menarche :
What is the menstrual pattern ? (Regularity, duration, quantity
of bleeding)
Other system:
DO you have : (Chest pain, Dyspnea, Orthopnea, PND, Palpitations, Syncope,
Ankle swelling , Easy fatigue , Intermittent claudication , Cold extremities ,
Cyanosis) (CVS)
DO you have : ( Wheeze, Cough, Sputum, Hemoptysis, Chest pain, Dyspnea,
DO you have : (Vomiting, Nausea Heart burn, Abdominal pain, Change bowel
habit) (GIT)
DO you have :( Headache, Neck pain, Visual disturbance, Seizures, Limb
weakness) (CNS)
DO you have :( Dysuria, Hematuria, incontinence, polyuria ) (GU)
DO you have :( Joint pain, Bone pain, Anemia ) ( Hematology+Rheumatology )
240 DO you have :( Bruising, Itchiness ,Color changes, Rashes, Swelling) ( Skin)
8. Past Medical Hx
• Trauma to the breast ?
8. Past surgical Hx:

10. Drug & allergic history :

• Do you take any medications ? or have you taken any recently ?
11. Family history :

discharge ?)
blood diseases)
12. Social history :

- Educational level
- Occupation
- Sexual contact
13- Differential diagnosis :

Discharge from surface :
- Paget’s disease
- Skin disease ( Eczema)
Discharge from single duct :
Nipple discharge 1- Blood Stained:
- Intraductual Carcinoma
- Intraductual Papilloma
- Duct Ectasia
2- Serous ( anycolor )
- Fibrocystic Disease 241
cont.
Discharge from more than one duct :
1. Blood Stained :
- Carcinoma
- Duct Ectasia
- Fibrocystic Disease
2. Green or Black :
Nipple discharge - Duct Ectasia
3. Purulent:
- Infection
4. Milk : -
- Lactation
- Hypothyroidism
- pituitary Tumor
242 Reference : AL-Qahtani, ABC 32 and ABC 31

Breast Examination
1. [WIPPE + ABCDEV]
NB: relax the patient in semi recumbent position ( 45 )
2.Inspection of both breasts :

Position benefits
1.With patient hands' Down Symmetry of both breasts and comparing
the level of nipples
2.With patient arms over the head Skin changes related to cancer Is More
prominent and to see axillae and undersur-
face of breast
3.With hands against her hips It may show any lump with tense pectoralis
major
NB: inspect the size ,symmetry, skin change .
3. [Inspection Of Affected Breast] :

1- Nipple &Areola :
- its Presence or absence.
- Colour.
- Asymmetry (retraction)
- Discharge -
- Duplication
2- Skin:
- Signs Of Inflammation ( Redness - Shines- Edema ) Dilated Veins ( Indi-
cates Sarcoma ) Dimpling, Puckering, Peudo’range, ulceration.
N.B: If There Is Visible Mass Describe It ( N + 6S ) :

● Number .
● Site .
● Size : Better In Centimeters .
● Shape : Irregular - Oval - Rounded
● Skin Overlying : Dilated Veins - Peudo’range - Dimpling - Puckering .
● Surroundings : Enlarged Lymph Nodes .
● Special Character .
3- Arms, Axilla and supraclavicular fossa:

[For any swelling or ulceration.]
4.[Palpation]:
•Patient should be in a semi-recumbent position
•Palpate with the palmar surface of the flat finger 243
• Palpate systematically each quadrant in turn then centrally around the
nipple then Axillary tail .
•Palpate the normal side first.
• Palpate the affected breast
(All quadrants) and axillary tail and assess
any lump.
• Palpate the nipple; if the nipple is retracted press gently to each side to
see if it will evert, and ask if this change is recent.
Look for : any lumps or discharge.
• Palpate axilla and supraclavicular fossa; lymph nodes and walls of axilla.
• Examine the arm;
swelling, oedema and other abnormalities.
● Attachment of the lump:

1- To Skin :
• Not Related To Overlying Skin : Skin Can Be Pinched , the lump can be
moved anywhere without moving the skin
• Tethering : the skin will indents when you pull the lump outside the arc
• Fixation : the lump cannot be moved without moving the skin
• Infiltrate The Skin : Moves With Movement Of Skin .
2- To Breast Tissue :
• Fix The Breast Tissues By One Hand And Move The Mass By Another Hand .
3- To underllying Muscles :
• To Pectoralis Major : Try To Move The Mass While Pushing Against The
Waist
• To Serratus Anterior : Try To Move The Mass While Pushing Against The
Wall .
4- To Chest Wall :
• The Mass Is Fixed And Immobile From The Start [ While The Patient Is
Relaxed]
The Draining LNs : 1. Axillary LNs .Supraclavicular LNs .
5. [ General examination ] :
Do complete general examination and look for any evidence of distant metas-
tasis in breast cancer
• Chest : Examine the chest and percuss the base of the lung for any evidence
of plural effusion ( lung metastasis)
• Abdomen : look for hepatomegaly and ascites
• Lumber spine : look for tenderness and limitation of movement ( percuss over
the spine ) suggestive of bone metastasis .
• Ankle jerks .
244 Reference : AL-Qahtani, ABC 32

Sinus and fistula chapter
Raghad Musallum Alhejaili
Hotaf Saeed Bafhaid
Revised by:
246
Sinus and Fistula
Definitions :
A sinus is a tract lined by granulation tissue that connects a cavity with an epi-
thelial surface, for example the skin (e.g. Perianal abscess).
A fistula is a pathological connection between two epithelial surfaces (e.g. Pi-

lonidal sinus).
sinus fistula
History of Sinus and Fistula

1-Personal Data :

A sinus or fistula in the perianal area, Its duration (minutes/hours/days/months/
years)

• Onset : When was the sinus or fistula first noticed?
• Special association: What drew the patient’s attention to the sinus or
fistula? (Pain, pus, discharge, bleeding, smell)
• Progression: Does it change with time?
• Multiplicity: Did the patient have a similar sinus or fistula before? At the
same site or elsewhere?
• Cause: What does the patient think is the cause of their condition?
• Previous Hx: What treatment has been suggested or administered before?
(Important in surgical management)
247
History of Sinus and Fistula .. cont.
• Perianal pain
• Discharge onset of severe,
throbbing pain, which
• Bleeding makes sitting, moving
• Pus and defecation painful
• Change in bowel movement is usually seen in
ano-rectal abscess
• Swelling
5-Risk Factors :
• The presence of chronic inflammation as TB or
actinomycosis, crhon’s disease, syphilis. a watery or purulent
discharge from the
• The presence of a malignant disease. external opening of
• Drugs (e.g. Steroids) the fistula is the most
common symptom of
• Irradiation (e.g. rectovaginal fistula after radiotherapy fistula-in-ano
for cervix cancer)
• Foreign body, e,g. a stitch.
• Obesity
• Poor hygiene / poor wound
pain and swelling in
the natal cleft is most
6-Constitutional Symptoms : commonly seen in
Fever, Fatigue, Weight loss, Loss of appetite and Pilonidal sinus .
Night sweating
7-Systemic Review :
• CNS: headache – irritability
• CVS: chest pain – palpitation – SOB – PND – orthopnea – calf claudication
• Respiratory : rhinorrhea – ear pain – throat pain - SOB – cough – wheeze
• Urinary: frequency – dysuria – hematuria
• Genital: pain – discharge
• Musculoskeletal: joint swelling or pain – bone pain
• Hematological: pallor – bruises
• Skin: rash – itching

• Any previous history of similar attack (Perianal abscess/swelling?)
• Any chronic diseases? e.g. IBD, DM, HTN, TB, carcinoma, lymphoma, leuke-
mia, inflammatory pelvic conditions(appendicitis) and diverticular disease.
• Previous hospitalization (Why?) for or a similar or different cause.

• Any previous operations? (Type, When, Complications, Outcome)
• Any blood transfusion?

• Any drug that the patient is using? (steroids)
248
• Allergies to food, drugs, dust.. etc.
History of Sinus and Fistula .. cont.
11-Family History :
• Chronic diseases in the family e.g. IBD, DM, HTN, heart disease and hemato-
logical diseases
• Cancer

• Marital status, and if there are any children
• Educational Level
• Occupation
• Smoking: either passive or active (ask about type, duration, no. of packs per
• Alcohol & Drug Abuse
• Travelling & Immunization
• Sexual contact
• Physical activity.
249
Sinuses & Fistula Examination
Start your examination with :
WIPPPER:
•Wash Your Hands.
•Permission.
•Privacy.
•Position.
•Exposure : from the nipple to the middle of the thigh and position
the patient in a lateral decubitus position.
•Right Side of the Patient :
1. Explain what you would like to do.
2- General Inspection: ABCDEV
Local Examination:
- Inspection:
• Site: (low level or high level: helps in management)
• Discharge: color, amount, smell(foul smell in perianal abcess)
• Depth: (‘til the bone or not: pilonidal sinus)
- Palpation:
• Surrounding (induration of skin in pilonidal sinus)
• Relation to surrounding structure (usually tenderness)
• Regional L.N. : (acute inflammation or carcinoma)
• State of local examination (blood vessels, nerves)
At the end of the Examination:

Abdominal examination
Genital examination
Goodsall’s rule: states that the internal opening of an anterior fistula lies along
a radial line drawn from the external opening to the anus, but the internal
opening of a posterior fistula always lies in the midline posteriorly. Although
things are rarely certain in medicine, this rule is reliable.
PNS is associated with hirsute men and

causes pain and Swelling in natal cleft,
purulent discharge if infected)
250
Differential diagnosis :
Sinus DDX :
1- Pilonidal sinus .
2- Infectious :Wound infection (e.g. hx of surgery or trauma )
Fistula DDX :
1- Anorectal abscess
2- Trumatic : Sexual abuse
3- Infectious :TB actinomycoses
4- Neoplastic : Anal carcinoma
5- Inflammatory : Crohn’s disease
Examination Pilonidal sinus Fistula-in-ano

the midline of the natal cleft be- cluster of granulation tissue any-
Position
tween the coccyx and the anus. where around the anus.
skin over a pilonidal Opening of fistula : not painful
Tenderness
abscess is red and tender. Tissue around : tender
Discharge purulent discharge are common usually purulent
internal opening of the fistula can
Rectal examina-
---- be felt as an area of induration
tion
beneath the mucosa
Sigmoidoscopy & exclude Crohn’s disease, ulcer-
Not done
Proctoscopy ative colitis, anal carcinoma
The inguinal lymph glands are inguinal lymph glands are
Local lymph gland
not enlarged not enlarged.
History (Case) Summary :

A 31 years old Saudi male patient, obese, smoker was admitted through E.R.
complaining of a lump, acute throbbing pain and swelling in the natal cleft for
4 days. The lump has increased in size but there was no discharge, no history of
trauma, injuries or another lump elsewhere and no fever.
Examination Summary :
Local exmaintion:
Inspection :
3xS: Site , Size and Shape
2xD : Discharge and Depth
1xE : Edge
Palpation :
- surrounding structure and its realtion
- Regional L.N
References:
• Clinical ABCs Batch31
• ABC to Surgery Batch32
• Browse’s Introduction to The Symptoms and Signs of Surgical Disease 5ed, pages 129, 130, 548, 549,550 and 551
•Clinical surgery Cuschieri Page 422 251
For your notes
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252 ....................................................................................
Urology chapter
Mohammed Salem Alqithami
Sahal Mohamed Alsuwayhri
Revised by:
Hassan Sameer Tawakkul
254
History of gross Hematuria
1- Personal data :
[Name, Age, Gender, Nationality, Route of Admission through OPD or ER]
2- Chief Complain :
Blood in the urine
(is it with urine or just blood from the meatus)
( in the female ask about the menstrual cycle)
3- HPI:
• First time?
• Duration
• Site: only hematuria or any bleeding from other site
• Amount?
• Timing:
Does blood appear at the start of urination [Prostate or urethra]
Or at the end of urination [prostate or Bladder]
Or throughout urination [upper urinary tract].
• Fresh or dark?
• association:
a) Pain?
(painless hematuria is considered bladder cancer until proven otherwise)
b) Clots?
• Fever
• Abdominal pain/ Suprapubic pain
• Nausea and vomiting
• LUTS: lower urinary tract symptoms :
a) [Voiding symptoms]: Hesitancy (sensation of incomplete empty-
ing), poor flow, intermittent
flow, post micturition dribbling, double micturition, or urinary reten-
tion.
b) [Storage symptoms]: Increase frequency of micturition, urgency,
nocturia, incontinence
-Dysuria, polyuria, oliguria.
• Anemia symptoms: (severity assessment): dizziness, palpitation, fa-
tigue, or pallor
• Past medical history:

smoking, History of stones, chronic kidney disease, DM, HTN, autoimmune
disease, hematological disease, malignancy
• Past surgical history:

recent instrumentation (cystoscopy, ureteroscopy, folly’s catheter), trauma .
255
History of gross Hematuria .. cont.
• Medications :
anticoagulants, rifampin, isoniazid, or phenazopyridine, chemotherapy
(hemorrhagic cystitis), radiation.
• Constitutional symptoms :
- Fever
- loss of weight
- loss of appetite
- Night sweat
- Fatigue (imp. In Cancer and TB infection)
• Systematic review:
- Hematologic: Easy bruising/bleeding, Gum Bleeding, Rash.
- GI: appetite, nausea, vomiting, change in bowel habit, hematemesis, mele-
na, hematochezia, abdominal pain, jaundice.
- Renal: lower limb Edema, eyelid edema (renal disease).
- Musculoskeletal: muscle weakness or pain, joint swelling or pain, bone pain
(metastasis from prostate cancer).
- CNS: Headache, confusion, tremors, weakness, paralysis, fainting, seizures,
numbness, loss of sensation, deafness, blurred vision.
- CVS: dyspnea, orthopnea, PND, edema, syncope, intermittent claudication
chest pain.
- Respiratory: runny nose, sore throat, shortness of breath, wheeze, cough,
sputum, hemoptysis.
6- Risk factor :
- Gender: female in UTI, male in Stone and Cancer.
- Age: young sexually active females, elder males with BPH or Tumor in the
urinary tract.
- Anomaly in Urinary tract.
- Pregnancy in UTI.
- D.M in UTI.
- Indwelling catheter in UTI and Trauma.
- Previous UTI or recurrent or chronic UTI.
- History of trauma (Blunt or crush injury to the abdomen or the pelvis).
- History of traveling (malaria & Schistosomiasis).
- History of blood diseases (e.g. sickle cell anemia),
- Anticoagulant medication
- History of Stone.
- Family history of renal disease (like polycystic Kidney disease) or stone.
- Anemic patient.
- Kidney biopsy.
- Recent URTI.
- Smoking in Bladder carcinoma.
256 - Exposure to dyes and solvents is a risk factor for bladder cancer.
7- Drug and allergy :
• Any drug that the patient is using? (mention the relevant)
• Allergies to food, drugs, dust.. etc.
8- Family History:
- Chronic diseases in the family (mention the relevant)
- anemia
- Genetic diseases
- Cancer
9- Social History:
- Educational Level
- Occupation
- Smoking: either passive or active (ask about type, duration, no. of packs per
13- Sexual History
14- Ddx:
Upper UTI: (Pyelonephritis) Fever, dysuria, Flank pain or back pain, total he-
maturia, cloudy urine, headache, malaise, vomiting.
Cystitis: dysuria, increased frequency and urgency of micturi-
tion, suprapubic pain, terminal hematuria, cloudy malodorous
Lower UTI: urine.
Favors UTI
Urethritis: dysuria, purulent discharge.
TB: can affect anywhere in the urogenital tract. There may be loin pain (from
ureteric obstruction), hematuria, or Lower urinary tract symptoms. weight
loss, night sweat and chronic chest symptoms. history of Recurrent UTI usu-
ally with –ve culture.
Renal calculi: dull aching pain in the loin with hematuria.
Favors cal- Bladder calculi:Symptoms of bladder outflow obstruction commonly in-
culi creased frequency of micturition. Sometimes sudden onset of stabbing pain
which relived when lying down. Terminal hematuria.
Renal: hematuria (intermittent), malaise, weight loss, bone pain, pathologic
fracture, loin pain (clot obstruct the ureter), varicocele and edema (occlu-
sion of left renal and testicular artery or IVC), abdominal pain
Favors Neo- Bladder: Bright red hematuria, the passage of blood clots cause pain and
plasm difficulty in micturition.
Being Prostatic hyperplasia: Voiding symptoms and storage symptoms.
Prostate cancer: Voiding symptoms and bone pain (pelvis and lumber spine
because of metastasize).
257
cont. :
IgA nephropathy Multiple recurrent episodes over months .
History of blunt or penetrating trauma, tenderness, bruising
Favors Trauma
and hematuria .
Use of anticoagulant drug, easy bruising or bleeding, pete-
Bleeding disorder
chiae, bleeding from other orifices.
History of taking medications like: Rifampicin, Nitrofuran-
toin, and Desferrioxamine. Hx of eating Food like beet root
Favors Red urine and berries.
Myoglobinuria from crush injury or Hemoglobinuria from he-
molysis .
258
History of Dysuria
1.Personal data :
[Name, Age, Gender, Nationality, Route of Admission Through OPD or ER]
2.Chief Complaint :
Burning sensation/pain with urination
(bladder CIS ”carcinoma in situ” may present with dysuria only)
3. History of presenting symptoms :

• Onset and duration of dysuria.
• Course (continuous or intermittent).
• Radiation of pain (eg, to loin or back, suggesting upper urinary tract
pathology).
• Pain:
*Is there suprapubic pain after voiding- eg, bladder inflammation or
infection
*Is there abdominal pain. (If it is present, consider abdominal pain
causes eg, appendicitis and ectopic pregnancy.)
• Severity, progression.
• Aggravating and reliving factors.
4. Associated symptoms :
• LUTS: lower urinary tract infection (BPH, cystitis, stone,malignancy)
• Fever, rigors or malaise (suggest pyelonephritis.)
• Hematuria (occurs with infection, stones, neoplasms and renal disease.)
• Urethral or vaginal discharge (consider genital tract infection.)
• Odor (suggests bacterial infection.)
• Pruritus (common with genital candidiasis.)
• Frequency and urgency (indicate bladder irritation.)
• Urine volume and flow - poor flow, intermittent flow (poor flow or anuria -
consider obstruction.)
• Post micturition dribbling, sensation of incomplete emptying
- Urogenital symptoms : frequency, nocturia, polydypsia, loin pain, hae-
maturia,Menarche,menopause, cycle, intermenstrual bleeding, post co-
ital bleeding.
5. Risk Factor:
• Bladder catheterization
• Exposure to dyes and solvents ( risk factor for bladder cancer)
• History of trauma
• History of traveling (Schistosoma)
• History of Stone
• Family history of renal disease or stone.
• Recent URTI. (post streptococcal infection)
•Smoking ( Bladder carcinoma) 259
History of Dysuria .. cont.
6. Constitutional symptoms :
• Fever
• loss of weight
• loss of appetite
• Night sweat
• Fatigue
7. Systemic Review :
- Hematological: easy bruising/bleeding, gum bleeding, Rash, palpitation,
joint swelling or pain.
- GIT: appetite, nausea, vomiting, change in bowel habit, stool color, hemate-
mesis, melena, hematochezia, abdominal pain, jaundice
- Bone: pain (metastasis from renal cancer or prostate cancer particularly at
pelvis and lumber spine), Edema, Varicose.
- Musculoskeletal: muscle weakness or pain, joint swelling or pain.
- Other systems :
• CVS.
• Respiratory.
8. Past Medical History :

- Past history: previous UTI, other genitourinary disease, Any chronic diseases?
- Occupation: exposure to dyes and solvents is a risk factor for bladder
- Cancer.
9. Past surgical History :

- Previous surgery , e.g. pelvic surgery or irradiation
- Any blood transfusion ?
10. Drug and allergy:

- Any drug that the patient is using? (mention the relevant)
11. Family History:

- Family history of similar symptoms.
- Chronic diseases in the family.
- Anemia.
- Genetic diseases.
- Cancer.
260
History of Dysuria .. cont.
12. Social History :
- Recent sexual history (bear in mind the possibility of child sexual abuse).
- Possible pregnancy.
- Educational Level
- Occupation
- Smoking: either passive or active (ask about type, duration, no. of packs per

Cystitis
1. Rapid onset
2. History of previous UTI
3. Urinary frequency
4. Sexual activity
Urethritis
1. Gradual onset (over days)
Infectious 2. Most common in young patients
3. Sexual activity
4. Urinary frequency
Pyelonephritis
1. Fever, rigors
2. Myalgia
3. Nausea, vomiting
4. Flank pain
Benign prostatic hyperplasia
1. Poor urinary flow
2. Nocturia
Others 3. Urinary hesitancy
Local irritants
History of use of scented soaps, vaginal
sprays, vaginal douches, bubble bath
References :
http://bestpractice.bmj.com/best-practice/monograph/299/diagnosis/differential-diagnosis.html
261
History of Urine incontinence
Introduce yourself, take permission from the patient
1-Personal Data :

Involuntary loss of urine, Duration (For how long ?)

- Onset: When did it start?
- Duration: How long?
- Progression: Is it get worse or improved?
- Course: Intermittent or continuous?
- Pattern: (loss with effort or no control at all)?
- Frequency: How many times you need to urinate?
- Amount?
- Color: bloody? Cloudy?
- Smelling\ Discharge: Any bad smelling? Discharge?
- Sensation: Can you feel when you need to urinate?
- type: urge (feel urge to urinate) or stress ( loss control of urine with
cough, lough)
- does it happen during sleep also? (sphincter)
Urogenital symptoms: frequency, nocturia, polydypsia, loin pain, haematu-
ria,Menarche,menopause, cycle, intermenstrual bleeding, post coital bleed-
ing.
Can you suppress your desire to urinate? Pain during urination ? pain with a
full bladder,?
Loss of urine when Coughing? Sneezing? Lifting? Bending?
Is there constipation?
Dysuria?
5-Risk Factors :
History of pelvic surgery, hysterectomy? or pelvic floor reconstructive proce-
dures? Spinal surgery?
Is there previous Patient with UTIs?
Did you have a Hx of Urethral obstruction?
Do you have Constipation?
Did you suffer from Depression?
Do you have Diabetes?
Is there Prostate disease?
Age of menopause ?
262
History of Urine incontinence .. cont.
7-Systemic Review :
- Musculoskeletal: myalgia, arthralgia, back pain, joint swelling.
- Endocrine: Thirst, Sweating, Prefer hot or cold weather, Fatigue, Neck swell-
ing, Hand trembling, Skin, hair & voice changes .

-Any chronic diseases? Multiple sclerosis, diabetes?
9- Past Surgical History (PSH) :

-Any previous operations? pelvic surgery, hysterectomy? or pelvic floor recon-
structive procedures? Spinal surgery? (Type, When, Complications, Outcome)
10- Drug and Allergy :

- Any drug that the patient is using?
- Any Cholinergic or anticholinergic drugs ?
- Over-the-counter allergy medications?
- Estrogen replacement?
- Beta-mimetics?
- Sedatives?
- Muscle relaxants?
- Diuretics?
- Angiotensin-converting enzyme (ACE) inhibitors?
11-Family History :
- Chronic diseases in the family : Neurological disease like Multiple sclerosis ,
diabetes affect neurological system.
- Genetic diseases
- Cancer ( prostate cancer)

-Educational Level
-Occupation
day then calculate it in pack-year) or Ex-smoker (for how long?) 263
History of Urine incontinence .. cont.
- And if related, ask about:, Sexual contact, Pets, Diet and Physical activity
History summary:
A 58 y/o women complains of urinary leakage after exertion. She loses urine
while coughing ,sneezing and playing golf. She underwent menopause 5 years
ago and is not on estrogen therapy .
14-Differential Diagnosis (DDx) :

Affected System Type Characteristics
Musculoskeletal system -Small amount of urine with cough-
(due to loss of bladder Stress incontinence ing and sneezing.
support) No urine lost at night?
-Large amount of urine without
Mainly neurological sys-
warning
tem (due to an overac- Urge incontinence
-Cannot suppress urge to void.
tive bladder )
-Urine loss day and night.
Symptoms of both stress inconti-
---- Mixed incontinence
nence and urge incontinence.
Neurological system due Small amount of urine lost intermit-
Overflow incontinence
to loss s3,s4 innervation. tently day and night .
Diuretics stimulating agent like:
Temporary urinary incon-
---- Alcohol,
tinence
Caffeine, diuretic drugs.
Mnemonic for the causes of transit Urinary incontinence :

DIAPERS
- Delirium
- Infection
- Atrophy
- Pharmaceuticals
- Excess urine output
- Restricted mobility
- Stool impaction
References :
1-http://emedicine.medscape.com/article/452289-clinical?pa=Vui0iydzdw4ndHIshWCnRx6wPNrjx-
WHwqTYC86%2Fmcytpp%2FfdDmf%2FMQb4eDfaJuVr58UO4zt6uCvfsH9C%2BrTSwl%2FDMAtBBAs-
M6eN9kpLn%2Fas%3D
2-http://www.mayoclinic.org/diseases-conditions/urinary-incontinence/basics/causes/con-20037883
3-ABC – Surgery 32
264

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Clinical ABCs

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Batch 33 - UQU

Hassan Sameer Tawakkul

Maryam Farraj Aloqalaa

Sarah Khaled Alem

Bayan Muhammed Fatani

Abdulmohsen Mohammed Alsofi

Elaf Faisal Obaid

Dr. Amal Khotani

Dr. Sami Hammadi

Dr. Fahd Almalki

Dr. Ali Alkhatheri

Dr. Mohammed Saleh

Dr. Solaiman Justaniah

Dr. Rani Alsairafi

Dr. Basem Alshareef

Dr. Mohammed Mirza

Clinical ABC 33’s team 9

-Central nervous system 99

- Ulcers and Diabetic Foot 201

- Neck Masses and Thyroid Gland 211

- The Breast 229

- Sinus and Fistula 245

Shahad hani Almontaser

Zahraa Abdulla Assumairi

Razan Rashad Bughdadi

YOU SHOULD KEEP IN MIND:

2-Chief complain & duration:

3-History of presenting illness (HPI):

To make it easier just remember this mnemonic (SOCRATES + TP):

*For Quality: CCP ABC2O

8-Past medical history (PMH):

9-Past surgical history (PSH) :

10-Drug and allergy history:

System Position Exposure

D= Distress and deformity

Rawan Osama Mirza

Ebtihal Tariq Yamani

Salwa Obed AlOmairi

Bassam Adel Aljabri

Abdullah Bakur Bannani

2-Chief Complaint (CC)

3- History of Presenting Illness(HPI)

8- Past Medical History (PMH) :

9- Past Surgical History :

10-Drug and Allergy:

11- Family History

Clinical classification of angina from European society of Cardiology :

2-Chief Complaint (CC)

3- History of Presenting Illness(HPI)

9- Past Surgical History :

10-Drug and Allergy :

11- Family History :

13- Differential Diagnosis :

2-Chief Complaint (CC) :

3- History of Presenting Illness(HPI) :

8- Past Medical History (PMH) :

9- Past Surgical History :

10-Drug and Allergy :

11- Family History :

- Pulmonary function testing

2-Chief Complaint (CC) :

3- History of Presenting Illness(HPI) :

8- Past Medical History (PMH) :