Advanced Clinical Skills

UNIVERSIT Y OF OTAGO, WELLIN GTON

CHAPTER 1

Case History Taking

1. Before seeing the patient obtain basic information: Name, DOB, address, hospital number, admission date, consultant, bed, ward. 2. Greeting, establish purpose and name, ensure patient comfort, appropriate positioning. 3. Begin to note physical features: Apparent age, nutrition, distress, facies, body proportions, self care, accessory muscles, breath sounds, position, colouration, speech, mental status, gait. 4. Chief presenting concerns: no more than three. [Begin to formulate the possible diagnoses] 5. History of the presenting illness: Details of the presenting concerns, characteristics, evolution, associated symptoms and significant negatives. For some symptoms consider a template: CLOSER AIM. C Characteristics: Tell me about, What does it feel like?, Is it sharp, dull?, How long does it last? L Location: Where is it?, Do you get it anywhere else?

O Onset: When did it start?, How did it start?, What were you doing?, What did you notice first?, When were you last well? S Severity: How bad is it?, Did you have to stop what you were doing?, How does it affect you?, Did you need to go to bed?, On a scale of 1 10 E Evolution: How long did it last?, Did it change over time?, Is it getting worst/better/more frequent/less frequent?. Identify whether the problem is one that is a) new and recent onset, b) chronic, progressively worsening, c) a disease with attacks and asymptomatic episodes with no overall decline, or d) a disease that comes in attacks and is getting progressively worse. R Relieving and aggravating factors: What makes it worst/ better?, What do you do to get relief?, What brings it on/makes it worse?, Is it worse when you move/breath/exercise/eat?. A Associated symptoms: When it happens, do you notice anything else?, Use symptoms from the System Review, as appropriate for closed questioning. Seek out significant negatives. I Impact: How has it affected your daily life?, How have others responded to your illness?, Has it affected you financially?. M Medications: what medicines were you taking when it began?, What are you taking now?, Have you tried alternative treatment?, Have you had side effects from medication?.

Refine differential diagnosis based upon disease likelihood and prognosis. Ask any relevant questions to refine the diagnosis further from past medical history, medication, family history, social history, travel history, or System Review. 6. Past medical History: Hospital admissions, surgery, medical problems. 7. Medications: All current and recent medications (tablets, creams, inhalers), including the name, dose, time of administration, frequency of use, indications, missed doses. 8. Allergies and intolerances. 9. Family history: Cause of mortality/morbidity of first degree relatives 10. Social history: Alcohol, smoking, drug use, exercise, occupation, marital status, family structure, pets, service requirements, language and communication. 11. Travel history: Relevant travel overseas. 12. Systems Review General: Change in appetite, weight, energy, sleep, mood. Rigors, fevers, abnormal sweating. Cardiovascular: Heart attack, high blood pressure, rheumatic fever, chest pain, palpitations, shortness of breath, exercise intolerance,

orthopnoea, PND, varicose veins/leg ulcers, ankle swelling, leg pain at rest/exertion. Respiratory: Asthma, bronchitis, emphysema, tuberculosis, wheezy breathing, cough, haemoptysis, pleuritic pain, sputum production, recent colds or flu, recent fevers, night sweats, snore loudly, daytime sleepiness (OSA), previous chest X-Ray. Female breast: Bleeding/discharge, previous mammogram, lumps. Gastrointestinal: Hepatitis, stomach ulcer, colitis, bowel cancer, dental problems, dentures, difficulty swallowing, pain on swallowing, jaundice, abdominal pain, nausea, vomiting, haematemesis, lump (groin/abdomen), food intolerances, changes in appetite, change in weight, current diet, indigestion/hearburn, antacid use, change in bowel habit, change in stool colour, stool frequency, dark urine/pale stool, blood on toilet paper, laxative use. Genitourinary: UTI, renal stones, pain on urination, loin pain, incontinence (stress/urge), frequency, nocturia, urgency, haematuria. Male urinary: Poor stream, dribbling, incontinence, urethral discharge, difficulty starting, erectile difficulties. Menstrual history: LMP, regularity/timing of the periods, excessive pain with periods, length of periods, last cervical smear, abnormal bleeding, vaginal discharge, possibility of pregnancy, timing of menopause.

 Lymphatic/haematological: Bleeding, bruising, anaemia, lumps in the neck, axillae or groin, blood clots. Nervous System: Stroke or TIA, migraine, headaches, memory, concentration, visual change/loss, weakness, altered sensation, vertigo, syncope, balance, deafness, tinnitus. Musculoskeletal: Arthritis, gout, difficulty dressing, climbing stairs, aids (sticks), muscle pains/cramps, joint pain, stiffness, altered function, back or neck pain, morning stiffness, dry eyes or mouth, falls, TMJ clicking or locking. Skin: Rashes, itching, changes to hair, nails or moles. Any concerning lesions. Endocrine: Diabetes, goiter, thyroid problems, change in sweating, heat intolerance, cold intolerance, excessive thirst.

CHAPTER 2

Physical Examination
End of the bed: Apparent age, nutrition, distress, facies, body proportions, self care, accessory muscles, breath sounds, position, colouration. Catheters, equipment and monitoring. Medicines, oxygen, inhalers, sputum pottles, walking stick. Handshake: Sweating, temperature, tremor, power, deformity. Hands: Nails (dystrophic changes, transverse and longitudinal lines, colour changes, clubbing, infections), palmar crease colour, Janeway lesions, Oslers nodes, thenar wasting, Dupuytrens, tendon xanthoma, nodules, joint swelling or deformity. Wrist tenderness. Forearms: shunt, radial harvest, cuts, needle marks, scratch marks, bruising. Pulse: Radial (rate, rhythm, paradoxus, alternans), radio-radial delay. Brachial (pulse countour, bisferiens). Respiratory rate and pattern. Blood pressure: By palpation first, the cuff. Repeat if >140 or <100 mmHg. Compare Left and Right. Valsalva response. Measure paradoxus, alternans. Detect bisferiens. Standing BP immediate and after 2 minutes.

 Axilla: Nodes (left and right axilla 4 groups). Discolouration. Head: Hair, eyes (jaudice, red or blue sclera, ptosis, conjunctival rim pallor, arcus, xanthelasmata, fundi). Nose (secretions, bleeding, septal deviation, polyps, rhinophyma, sinus tenderness). Malar flush. Ear (discharge, creases, hairy ears, tophi, CNH, otoscopy). Mouth (dental hygiene, leucoplakia, SCC, salivary ducts, gums, tongue, palate, uvula, odours). Neck: Carotid bruit, carotid palpation (contour, bisferiens), jugular vein (pressure, contour and abdomino-jugular reflux), trachea centrality, tracheal movement, laryngeal height, forced expiratory time, salivary glands (sublingual, submandibular and parotid), lymph nodes (supraclavicular, superficial and deep cervical, posterior cervical, tonsillar, submandibular, pre- and post-auricular, occipital), thyroid (contour and palpation), scars, masses and swellings. Chest General: Spider naevi, gynaecomastia. Chest Cardiac: Scars (sternotomy, chest drains), deformity (pectus excavatum), pulsations, thrills, apical impulse (position, duration, size), palpable P2, precordial percussion, auscultation (mitral, tricuspid, Erbs, pulmonary and aortic areas). Diaphragm in all areas listening for intensity of S1/S2, splitting S1/S2, murmurs (note distribution), extra sounds. Lateral decubitus over apical area with bell for S3, S4 and mitral stenotic murmur. Sitting in expiration, over Erbs point with diaphragm, for aortic regurgitation. Crackles, posturally induced crackles.

 Chest Respiratory: Shape, deformity, tenderness, fremitus (toy coin), percussion. Auscultation breath sound (bronchial or vesicular), adventitious sounds (crackles, wheeze, ronchi, rubs), voice sounds, bronchophony (111), egophony (Eee), whispered pectoriloquy (111). Breath Sound Intensity (6 sites, n/24). Posterior chest and spine: deformity, kyphoscoliosis, expansion upper and lower lobes. Fremitus, percussion, auscultation and voice sounds. Renal angles: Posterior renal bruit, percussion tenderness. Sacral area: Oedema Abdomen: Inspection (symmetry, scars, pulsations, distention, venous patterns, herniae, movement). Auscultation (bowel sounds, aortic, anterior renal, iliac bruit). Percussion (masses, flatus, faeces, organs). Shifting dullness. Light palpation (guarding rigidity), deep palpation (masses). Gall bladder (Murphys sign). Liver: Percuss upper edge and lower edge. Scratch and palpate lower edge. Spleen: Percuss over Traubes space (6th rib, costal margin and AAL). Percuss Castells point on inspiration and expiration (ALL, last interspace). Palpation. Aorta: palpation. Bladder: percussion, scratch, palpation. Kidneys: Ballotment. Rectum: Haemorrhoids, sphincter tone, rectal palpation, prostate, tenderness. FOB. Genitalia: Male: Penis, scrotum, testes, cord, swellings, tenderness, masses. Female: Labia, digital exam, cervix, ovaries.
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 Groin: Herniae (cough and standing). Femoral artery palpation and auscultation for bruit, radio-femoral delay. Knee: Palpation popliteal artery. Legs: Varicosities, ulceration, swelling, calf tenderness. Ankle: Palpation DP and PT arteries (R and L). Ankle-Brachial Pressure Index. Feet: Nails, infection, ulceration, sensation (Semmes-Weinstein monofilament).

CHAPTER 3

Neurological Examination
Gait: Antalgic (painful) gait (short step on the painful side): Foot (foot contacts the ground abnormally); knee (stiff knee that does not extend or flex fully); hip (coxalgic lateral lurch to the side of pain). Muscle weakness gaits: Trendelenburg (excessive drop of opposite pelvis), gluteus maximus (backward lean during stance phase), weak quadriceps, footdrop (high stepping, foot slapping). Spasticity: Hemiplegic (arm flexed, circumducting motion of paralysed leg), diplegic gaits (slow, laborious, stiff-legged). Rigidity: Parkinsonian (flexed posture, narrow base, shuffling). Ataxic gait (wide base, staggering). Mental Status: Behaviour and appearance, conversation, speech, paralanguage, thought content, mood, memory (recent and remote), calculation, insight, orientation (time, place, person). Cranial Nerves: I Smell (floral scent or coffee) II Visual field, acuity III, IV and VI Diplopia, ptosis, nystagmus, pursuit

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V Motor (jaw opening), sensory (light touch and pinprick V1, 2, 3) VII Facial movements VIII Hearing (whispered voice, Weber, Rinne) IX, X Palate and vocal cords (say Ah, cough) XI Trapezius (shrug), sternocleidomastoid (turn against resistance) XII Tongue (wasting, fasciculation, protrusion) Muscles: Fasciculation, wasting especially small muscles of hands (ulnar and median nerves), tibialis anterior and small muscles of the feet (peripheral neuropathy). Power/Movement: Shoulder abduction (C5), Adduction (C6,7,8) and external rotation. Elbow flexion (C5, 6) and extension (C7, 8). Wrist flexion and extension (C6, 7). Finger extension at MCP and flexion at DIP (C7, 8). Finger abduction (T1). Thumb abduction. Hip flexion (L1, 2,3) and extension (L5). Knee flexion (L5, S1, S2) and extension (L3, 4). Ankle inversion (L4), dorsiflexion (L4, 5), eversion (L5, S1) and plantar flexion (S1, 2). Tone in arms and legs. Co-ordnation (finger-nose; heel-shin; heel-toe walking). Reflexes: Biceps (C5, 6), supinator (C5, 6), triceps (C7, 8), knee (L3, 4), ankle (S1, 2) and plantar response. Sensation: Vibration and position at distal fingers and toes; light touch and pinprick at face (V1, 2, 3), and distal hands and feet (just proximal to nail bed).

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CHAPTER 4

Musculoskeletal Exam (GALS)

Gait: Walk a few steps, turn and walk back. Note symmetry, smoothness, and ability to turn quickly. While standing, observe from front, side and back, and note bulk and symmetry of shoulder, gluteal, quadriceps and calf muscles. Arms: Hands behind head. Arms out with fingers outstretched and palms down note swelling and deformities. Turn palms over note muscle bulk. Make a fist note hand and wrist function. Gently squeeze each MCP joint for tenderness. Legs: Lying on bed supine across flexion and extesion and feel for crepitus. With hip and knee flexed to 90, hold knee and ankle assess internal rotation of each hip in flexion. Patellar tap. Inspect feet for deformity, callouses, swelling. Squeeze across MTP joints for tenderness. Spine: Patient standing inspect from behind for scoliosis, and from side for abnormal lordosis and kyphosis. Head tilt to each shoulder. Touch your toes.

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CHAPTER 5

Dermatological Examination
Appearance: Colour, shape, size, elevation or depression, edge. Palpation: Surface texture, induration (hardness), tenderness. Distribution on body. Distribution relative to each other: Clustered, confluent, dermatomal. Configuration: Annular, linear, reticular. Skin lesion to recognise: Eczema, spider naevi, seborrheic keratoses, moles, Campbell de Morgan spots (cherry angiomata), psoriasis, acanthosis nigricans, rosacea, pemphigoid, pemphigus, lupus erythematosis, lichen planus, erythroderma, scleroderma, erythema multiforme, erythema nodosum, acne, infections, intertrigo, erysipelas, cellulitis, impetigo, paronychia, tinea (corporis, capitis, pedis, manuum), candidiasis, tinea versicolour, herpes, pitted keratolysis, pityriasis rosea, warts, molluscum contagiosum, scabies, pediculosis. Cancers: Melanoma, Squamous Cell Carcinoma, Basal Cell Carcinoma.

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