Physical Diagnosis



CLINICAL HISTORY

CHECKLIST

CLINICAL HISTORY

INTRODUCTION

Y N Comments

| - Introduced self by first and last name | | | |

|Demographic data including name, age, sex, nationality, occupation and marital status. | | | |

|Date and time of interview. | | | |

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|CHIEF COMPLAINT | | | |

|Symptom in patient words | | | |

|Duration of symptom | | | |

History of Present Illness

|Must elicit all of the following: | | | |

|1-Location 2 -Quality 3- Severity 4- Onset of symptom | | | |

|5- Radiation. 6- Modifying factor. 7-Associated Symptom. 8- Review the involved system. | | | |

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|PAST MEDICAL HISTORY |

| - Medical. | | | |

| - Surgical. | | | |

| - Trauma. | | | |

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|FAMILY HISTORY |

|Similar disease | | | |

|Common disease | | | |

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|DRUG HISORY |

|MEDICATIONS | | | |

| ALLERGIES |

|Drugs | | | |

|Food | | | |

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|Social History |

|Smoking | | | |

|Drugs abuse | | | |

|Alcohol intake | | | |

|Occupation | | | |

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|Review of systems | | | |

|Cardiovascular: Chest pain, palpitation... | | | | | | |

|Respiratory: Shortness of breath, cough… | | | | | | |

|Gastrointestinal: Bowel movement, appetite… | | | | | | |

|Musculoskeletal: Joint pain, swelling… | | | | | | |

|Urogenital: Loin pain, hematuria… | | | | | | |

|Neurological: Numbness, weakness… | | | | | | |

|Psychiatric: Hallucination, sleep… | | | | | | |

|Endocrine: Weight, Heat tolerance… | | | | | | |

|Hematologic: Bleeding tendency, epistaxis… | | | | | | |

|Immunologic: Repeated infection, neck swelling… | | | | | | |

|Skin: Rash and itching. | | | | | | |

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PHYSICAL EXAMINATION

VITAL SIGNS

A B C

|BLOOD PRESSURE RECORDING | | | | |

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|TEMPERTURE | | | | |

|PULSE | | | | |

|RESPIRATION | | | | |

|WEIGHT AND HIGH ( BMI ) | | | | |

Neck

1-LYMPH NODES A B C Comments

| Examine from the back of the patient | | | | |

|Pre-auricular – in front of ears | | | | |

|Post-auricular – behind the ears | | | | |

|Occipital – base of the back of the neck | | | | |

|Posterior cervical – back of the sternomastoid muscle | | | | |

|Cervical-tonsillar – angle of jaw | | | | |

|Submandibular – halfway between angle of jaw and chin | | | | |

|Submental – center of body under chin | | | | |

|Cervical chain – along sternomastoid muscle | | | | |

|Supraclavicular – in angle formed by collarbone and | | | | |

| sternomastoid muscle. | | | | |

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|2-TRACHEA | | | | |

|INSPECTION | | | | |

|PALPATION | | | | |

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|3-THYROID | | | | |

| POSITION OF EXAMINAR | | | | |

|INSPECTION ( ASK PATIENT TO SWALLOW ) | | | | |

|PALPATION FROM THE BACK | | | | |

|PERCUSSION OVER MANIBRIUM | | | | |

|AUSCLTATION FOR BRUIT | | | | |

| EYES | | | | |

|EYE INSPECTION: Examiner should ask you to look upward as examiner gently moves the lower lids of each | | | | |

|eye downward. In the same way, you should look downward as examiner gently moves the upper lids upward. | | | | |

| PUPIL RESPONSE: With lights off, examiner should shine a penlight or the light of the ophthalmoscope on | | | | |

|each pupil. Examiner should avoid shining the light into both pupils simultaneously and should not allow | | | | |

|you to focus on the light. | | | | |

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|OPHTHALMOSCOPY: With lights off, examiner should instruct you to look at a distant point directly in | | | | |

|front, and focus on that point. | | | | |

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| Chest and Lungs | | | | |

A B C Comments

|INSPECTION: in sitting position | | | | |

|Shape and symmetry. | | | | |

|Symmetry of respiratory expansion | | | | |

|Pulsations and apex beat | | | | |

|Respiratory distress | | | | |

|Palpation: front and back. | | | | |

|Trachea | | | | |

|Cardiac apex | | | | |

|Thoracic expansion | | | | |

|Tactile fremitus | | | | |

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| 3 – PERCUSSION : from one side to the other | | | | |

|Anterior from the apex and clavicle | | | | |

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|Posterior from the apex | | | | |

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|Axilla | | | | |

|Auscultation: using the diaphragm | | | | |

| POSTERIOR BREATH SOUNDS: Examiner should ask patient to breathe deeply and should move from one side of the| | | | |

|back across to the other and down. | | | | |

|ANTERIOR BREATH SOUNDS: Examiner should use stethoscope to listen to both sides of the front. Examiner | | | | |

|should progress from side to side moving downward using the same sequence while listening to one full | | | | |

|respiration on each location. | | | | |

|VOCAL RESONANCE: While auscultating with the stethoscope over the back, the examiner asks the patient to say| | | | |

|“.e-e-e” The examiner should move the stethoscope from one side to the other, moving downward, while | | | | |

|listening to patient say “e-e-e” at each location. | | | | |

Heart & Blood Vessels

A B C Comments

|JUGULAR VENOUS PULSE INSPECTION | | | | |

|Position of the patient in good light | | | | |

|PRECORDIAL EXAMINATION | | | | |

|Inspection: deformity, pulses …. | | | | |

|Palpation: heart apex , trachea , left sternal heave and | | | | |

|palpable second heart sound | | | | |

|Percussion (limited) | | | | |

|Auscultation : of four areas including: | | | | |

|Aortic , pulmonary , tricuspid and mitral | | | | |

|PULSES: includes radial, dorsalis pedis, posterior tibial and carotids. | | | | |

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Abdominal

A B C Comments

|INSPECTION: Shape, contour, symmetry, movement, scars, dilated veins and umbilicus. | | | | |

|PALPATION: | | | | |

|1- LIGHT PALPATION: palpate all four quadrants and the epigastrium lightly while using the palmar surface | | | | |

|of the fingers to identify any masses or areas of tenderness. | | | | |

|DEEP PALPATION: palpate all four quadrants and the epigastrium more DEEPLY while using the palmar surface | | | | |

|of the fingers. | | | | |

|LIVER MARGIN: start in lower right quadrant of abdomen and gently press in and upward. Patient should take| | | | |

|a deep breath and then exhale while moving the hand upward toward the right. | | | | |

|SPLEEN MARGIN: upwards against back. Right hand is placed below the left costal margin and pressed inward | | | | |

|toward the spleen. Examiner should start in the lower left quadrant and work up towards the upper left | | | | |

|quadrant | | | | |

|PERCUSSION: | | | | |

|Percussing the liver in the right mid-clavicular line at the level between the lower right chest and the | | | | |

|umbilicus and proceed superiorly. Then examiner should begin in the right mid-clavicular line over the | | | | |

|lung and proceed inferiorly to measure liver span. | | | | |

|Spleen percussion above lowest rib on the left anterior axillary line and then repeats while Pt holds a | | | | |

|deep breath. | | | | |

|Shifting dullness | | | | |

|Fluid thrill. | | | | |

|AORTIC PULSE: Examiner should use opposing thumb and finger or palmar surface of fingers and palpate the | | | | |

|aortic pulsation located in the upper abdomen slightly to the left of midline. | | | | |

|COSTO-VERTEBRAL ANGLE TENDERNESS: Examiner should use his/her fist and percuss the kidneys just under the | | | | |

|lowest rib posteriorly on both sides. | | | | |

|AUSCULTATION: | | | | |

|Listen to all four quadrants of the abdomen: right upper, left upper, right lower, and left lower for bowel| | | | |

|sound. Listen also over a mass for bruit. | | | | |

|Listen to the AORTIC artery (located in the middle of the abdomen above the umbilicus) for bruit. | | | | |

|The RENAL arteries (located above the umbilicus), the ILIAC arteries (located below the umbilicus, | | | | |

|bilaterally) | | | | |

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Neurological Examination

A B C Comments

|MENTAL STATUS: Level of consciousness, orientation (person, place, time, situation). Examiner should ask a | | | | |

|minimum of 3 questions, memory (remote and recent) and speech. | | | | |

| CRANIAL NERVES: | | | | |

| - Olfactory. | | | | |

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| - Optic: | | | | |

|Visual acuity, Visual field and fundi. | | | | |

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| - Third(Oculomotor),fourth(Trochlear) and | | | | |

|Sixth(Abducent): | | | | |

|Extraocular movement: Examiner should be | | | | |

|positioned in front of you and request that | | | | |

|without moving your head, your eyes follow | | | | |

|examiner’s finger or a pencil in four directions | | | | |

|(“H” or “+” ). Examiner should also ask you to look | | | | |

|at the tip of your nose | | | | |

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| Fifth (Trigeminal): | | | | |

|Clenching teeth while palpating the muscles of the jaw. Close his/her eyes and identify bilateral facial touch| | | | |

|as soft or sharp for the three branches (ophthalmic, maxillary and mandibular | | | | |

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|Seventh (Facial): | | | | |

|Squeeze eyes shut, raise eyebrows, wrinkle forehead, | | | | |

|Frown and whistle, etc. | | | | |

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|Eighth (Acoustic): | | | | |

|Hearing the ticking of watch or rubbing of fingers | | | | |

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|NINTH AND TENTH (Glossopharyngeal and Vague): | | | | |

|Gag reflex. | | | | |

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|ELEVETH (Spinal Accessory): | | | | |

|Push his/her head against examiners hand in a | | | | |

|Side- ways. | | | | |

|Shrug shoulders up against examiner hands. | | | | |

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|TWELVE (Hypoglossal): | | | | |

|Stick his/her tongue out of the mouth and move it | | | | |

|From side to side. | | | | |

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|Motor Examination | | | | | | | |

|INSPECTION: Wasting, abnormal movement, deformities and fasciculation. | | | | | | | |

|Tone: passive movement of different joints | | | | | | | |

|Strengths: Power grading (0-5). Ask patient to raise hands or legs. | | | | | | | |

|Reflexes(spinal or deep tendon): | | | | | | | |

|movement of the hammer should be a rapid | | | | | | | |

|downward snap of the wrist. The hammer should | | | | | | | |

|not be held too firmly. | | | | | | | |

|Each of the following reflexes should be tested | | | | | | | |

|bilaterall | | | | | | | |

|Biceps, Triceps, Brachioradial, Knee, Ankle and | | | | | | | |

|Planter. | | | | | | | |

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|COORDINATION OF UPPER EXTREMITIES: | | | | | | | |

|The examiner should ask patient to touch examiner’s index finger and patient’s nose. The examiner should place| | | | | | | |

|his/her index finger 18 inches from the patient while changing the location of his/her finger several times. | | | | | | | |

|This procedure should be repeated with the Pt’s other hand (finger-Nose-Finger). | | | | | | | |

|Rapid alternating movement. | | | | | | | |

|The examiner should ask each finger on patient to rapidly and repeatedly touch his/- her thumb with the same | | | | | | | |

|hand. Repeat with the Pt’s other hand. | | | | | | | |

|COORDINATION OF LOWER EXTREMITIES: | | | | | | | |

|The examiner should ask patient to run the heel of one foot up and down the shin of the opposite leg. | | | | | | | |

|Repeat with opposite leg (Heel to Shin) | | | | | | | |

|The examiner should ask patient to walk a straight line in a heel-to-toe fashion. | | | | | | | |

|ROMBERG SIGN: | | | | | | | |

|Examiner should observe patient stand with his/her arms stretched out in front or beside him/her with eyes | | | | | | | |

|closed. | | | | | | | |

|Gait: | | | | | | | |

|The examiner should observe patient walk, turn, and return. | | | | | | | |

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| |SENSORY FUNCTIONS: | | | | |

| |Compare two sides and patient should close his eyes | | | | |

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| |Superficial: touch, pinprick, pressure and | | | | |

| |Temperature. | | | | |

| |DEEP SENSATION: | | | | |

| |1-POSITION SENSE: The examiner should hold | | | | |

| |either side or the tip of patient’s finger with | | | | |

| |his/her two fingers. Examiner should then move | | | | |

| |the finger up or down and ask patient to say | | | | |

| |which way it is being moved. Repeat with the | | | | |

| |big toe. | | | | |

| |2-VIBRATION SENSE: | | | | |

| |The examiner should place a vibrating tuning | | | | |

| |fork against the bony prominence of patient’s wrist (Styloid process) and ankle (medial | | | | |

| |malleolus) | | | | |

| |and ask patient to state when the vibration stops | | | | |

| |CORTICAL SENSATION: | | | | |

| |Stereognosis, graphesthesia | | | | |

NECK SWELLING

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|Greeting the patient / self-introduction | | | | | |

|Explain to the patient and ask for permission | | | | | |

|Patient’s privacy | | | | | |

|Pull curtain and look for a nurse | | | | | |

|Positioning and adequate exposure | | | | | |

|INSPECTION: | | | | | |

|Location | | | | | |

|Single or multiple | | | | | |

|Size and shape | | | | | |

|Skin changes , discharges or sinus | | | | | |

|Moving with swallowing | | | | | |

|Move with tongue protrusions | | | | | |

|Neck veins | | | | | |

|Inspect oral cavity and eyes. | | | | | |

|PALPATION: | | | | | |

|Stand in front of the patient: | | | | | |

|Swelling tender or non-tender | | | | | |

|Tracheal position | | | | | |

|Stand behind the patient: | | | | | |

|Determine temperature, number, consistency, borders | | | | | |

|And movement with swallowing and attachment | | | | | |

|Pulsation and fluctuation | | | | | |

|Transillumination. | | | | | |

|Palpation of carotid pulse | | | | | |

|Palpation of lymph nodes | | | | | |

|PERCUSSION: Over manubrium of the sternum | | | | | |

|AUSCULTATION: over the swelling | | | | | |

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CLINICAL EXAMINATION OF BREAST LUMP

|Greeting the patient / self-introduction | | | | | |

|Explain to the patient and ask for permission | | | | | |

|Patient’s privacy | | | | | |

|Pull curtain and look for a nurse | | | | | |

|Positioning and ( semi prone or sitting ) | | | | | |

|Adequate exposure ( neck, both breasts and arm by the side) | | | | | |

| INSPECTION | | | | | |

|Inspect both breasts , normal side first | | | | | |

|Symmetry | | | | | |

|Obvious swelling | | | | | |

|Lump ( site , sizes and shape ) | | | | | |

|Skin changes, redness, edema, dimpling and ulceration. | | | | | |

|Areola | | | | | |

|Nipple ( level , retraction , ulceration and discharge ) | | | | | |

|Inspect breasts and axilla with arm over the head and hand | | | | | |

|pressing over hips | | | | | |

| PALPATION | | | | | |

|Ask for any painful area | | | | | |

|Palpate with the palmer surface of the fingers start normal breast | | | | | |

|Determine characteristics of lump using tip of the fingers: | | | | | |

|Site, size, shape, margins and consistency. | | | | | |

|Mobility , temperature and tenderness | | | | | |

|Numbers and attachment | | | | | |

|Palpate of areola: | | | | | |

|Mass | | | | | |

|Nipple discharge on pressure | | | | | |

|Palpate of nipple: | | | | | |

|Retraction | | | | | |

|Discharge | | | | | |

|Palpate axillary lymph nodes | | | | | |

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