Chest pain

When did it start What type of pain Where is it and where does it radiate to Is it worsened alleviated by breathing, posture, movement Is there localized tenderness Disorders affecting the respiratory system commonly produce a 'pleuritic-type' pain that is sharp, localized, exacerbated by breathing and coughing, or systemic manifestations, such as weight loss due to a bronchial malignancy. Is there fever, rigors, weight loss, malaise, night sweats, lymphadenopathy, skin rash ls there excessive...

Examination

Is the patient well or unwell Comfortable or uncomfortable Still or restless Eyes open (fearfully watching the doctor's abdominal examination ) or closed and relaxed Is there fever, anaemia, jaundice, lymphadenopathy, evidence of weight loss, malnutrition, foetor, ketosis Are they dehydrated, shocked, hypovolaemic Do they have an acute abdomen (See Chapter 90.) Could there be obstruction (distension, vomiting, absolute constipation, high-pitched tinkling bowel sounds) Is there tenderness,...

History

The classical description of the pain of aortic dissection is of a sudden (instantaneous), severe, tearing pain located in the back (often interscapular region). However, other presentations occur aortic dissection may present with sudden death, collapse, stroke, central anterior chest pain (mimicking acute MI), abdominal or leg pain. Accompanying symptoms may include nausea, sweating, vomiting and shortness of breath. The dissection can spread to involve other arteries such as the carotids...

Diabetic ketoacidosis

This can occur as the first presentation of diabetes mellitus or it can occur in those patients with known diabetes mellitus. There may be a gradual onset of symptoms with thirst and polyuria. Other symptoms include breathlessness, abdominal pain, drowsiness, confusion or even coma. On examination there may be evidence of acidosis (rapid, Kussmaul respiration deep and sighing ), of dehydration (with hypotension, tachycardia and postural fall in BP) or of preexisting diabetic damage (e.g....

Fever even PUO

A classical presentation would be with the sudden onset of pleuritic chest pain accompanied by breathlessness and haemoptysis or alternatively a sudden collapse in a postoperative patient shortly after straining at stool. Other patients may present simply with breathlessness, with pleuritic pain or with haemoptysis, but have little abnormality visible on chest X-ray. PE occurs in over 1 of hospital inpatients and significant pulmonary emboli are found unexpectedly in the postmortems of over 10...

Past medical history

Is there any history of previous stroke, TIA, amaurosis fugax, collapses, fits or subarachnoid haemorrhage Is there any history of any known vascular disease (e.g. carotid stenoses, coronary atherosclerosis, peripheral vascular disease) Is there any history of any known bleeding or clotting tendency Is there any possible embolic source (e.g. atrial fibrillation, prosthetic valve, carotid stenosis, carotid or vertebral dissection) Is there any history of hypertension, hypercholesterolaemia or...

Info

Acromegaly is the syndrome of excess growth hormone secretion, usually from a pituitary tumour. Acromegaly may present with the effects of excess growth hormone, such as a change in facial appearance or an increase in foot or hand size. The changes occur gradually and may be noticed by friends and family or when seeking medical attention for another complaint, such as hypertension or hyperglycaemia. Acromegaly has a prevalence of 6 100 000. The pituitary tumour can encroach upon the optic...

Chronic liver disease

Chronic liver disease may present with features of impaired synthetic function, such as oedema, bruising, jaundice or pruritus, with features of portal hypertension, such as asci-tes, abdominal pain or variceal haemorrhage, or with general malaise, fatigue and anorexia. Alternatively the underlying aetiology, such as excess alcohol consumption, may bring the problem to light or it may be discovered incidentally during routine blood testing. Important causes include alcohol-induced liver...

Past medical history drugs and allergies

Vaccinations Medicals Screening tests The PMH is a vital part of the history. It is important to record in detail all previous medical problems and their treatment. It is also useful to record this information in chronological order. You could ask 'What illnesses have you had' , 'What operations' , 'Have you ever been in hospital' , 'When did you last feel completely well' Ask if there were any problems with operations or anaesthetics, and, if so, what they were. You might turn up a bleeding...

Inspect gait

Look for steadiness, speed, stride length, arm swing, limping, favouring one leg over the other and ability turning. Perform the heel-toe test. Any features of spasticity, foot-drop, parkinsonism, apraxia (impairment of complex movements despite normal motor and sensory function), ataxia (unsteady, broad-based gait), etc Consider photography to document evidence Symmetrical Sun exposure Consider photography to document evidence Symmetrical Sun exposure

Rheumatoid arthritis

> Distal joints > proximal Swelling Tender ' Erythema Synovial thickening Effusion Deformity Rheumatoid arthritis is a symmetrical, deforming peripheral arthropathy. This is a common disorder, which affects women more frequently than men. Initially symptoms are of joint stiffness and swelling but, as the condition progresses, there may be substantial joint deformity and systemic features. It is the commonest inflammatory arthro-pathy with a prevalence of 1.5 .

J

Record, use and present the patient's actual words Great detail about each aspect of the history Tell me more about Could we focus on The history of the presenting complaint is by far the most important part of the history and examination. It usually provides the most important information in arriving at a differential diagnosis but also provides vital insight into the features of the complaints that the patient gives the greatest importance to. It should usually receive the greatest proportion...

Evidence

Clinical symptoms and signs are useful in the diagnosis of hypothyroidism but a high index of suspicion is required because hypothyroidism may exist with minimal symptoms and no classical signs. Table 77.1 Symptoms and signs in hypothyroidism. Frequency of sign Frequency of in hypothyroid sign in normal Table 77.1 Symptoms and signs in hypothyroidism. Frequency of sign Frequency of in hypothyroid sign in normal Zulewski H, Muller B, Exer P, Miserez AR, Staub JJ. Estimation of tissue...

Primary survey or ABCD

Begin the primary survey as soon as you see the patient. A quick look can tell you a lot. Are they breathing Do they look at you Is the cervical spine immobilized Is the airway preserved If not, correct with positioning (chin lift and jaw thrust), oral airway, suction and if necessary intubation (with in-line immobilization to protect the cervical spine). Ask 'How are you' If the patient responds in a clear voice, the airway is patent at present. A clear voice, quiet respirations and a normal...

Causes of dementia

Alzheimer's disease (common, dominant memory impairment with gradual decline). Vascular dementia (fluctuating course ). Pick's disease (prominent frontal lobe signs, disinhibition, primitive reflexes). Dementia with parkinsonism (e.g. Lewy body dementia). Normal pressure hydrocephalus (gait disorder, urinary incontinence and cognitive decline). Creutzfeld-Jakob disease (rare, rapid decline, myoclonus though this can be seen in other dementias ). Treatable causes of dementia include Cerebral...

Presenting a history and examination

The detail required will vary markedly depending upon the case, the context and the audience. It is imagined here that a patient has just been clerked on take by a junior doctor and is now to be presented to a consultant on the post-take ward round. In general, be concise and omit negative pieces of information but important, relevant negatives should be included. The priorities are to communicate the patient's name, gender and age, to describe in detail the presenting com-plaint(s), to...

Worrying red flag features of back pain

1 Cancer as a cause of back pain Age > 50 years or < 20 years. Failure to improve with therapy. Pain persists for more than 4 weeks. Night pain or pain at rest. 2 Infection as a cause of back pain History of intravenous drug abuse. Recent bacterial infection. 3 Cauda equina syndrome as a cause of back pain (due to large central disc protrusion or other cause of lumbar canal stenosis) Urinary incontinence or retention. Anal sphincter tone decreased or faecal incontinence. Bilateral leg...

Hypoglycaemia

Hypoglycaemia occurs commonly in diabetics due to insulin or hypoglycaemic administration or during times of inadequate caloric intake. It can also occur in alcoholics, with tumours secreting glucagon, with malnutrition and, rarely, in sepsis. The symptoms of hypoglycaemia are a feeling of hunger, jitteriness, faint feeling, tachycardia, sweating and a range of neurological symptoms from headache to neurological deficits to coma. The prompt recognition of hypoglycaemia is essential so that...

Examine the eyes with an ophthalmoscope

The ophthalmoscopic examination of the eye is a vital part of the complete physical examination. It can reveal the effects of systemic conditions such as hypertension and diabetes mellitus, causes of visual dysfunction such as optic atrophy, and reveal conditions such as raised intra-cranial pressure by demonstrating papilloedema. The ocular complications of conditions such as diabetes mellitus may be asymptomatic until sight-threatening complications have developed hence the importance of...

Definition

Clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (i.e. not lifelong), is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reduction in previous levels of occupational, educational, social or personal activities. Together with the concurrent occurrence of four or more of the following symptoms substantial impairment in short-term memory or concentration, sore throat, tender lymph...

Polycystic kidney disease

Peritoneal Dialysis Nurses History

Tenckhoff catheter for peritoneal dialysis Tenckhoff catheter for peritoneal dialysis Polycystic kidney disease is inherited in an autosomal dominant manner in which gradually enlarging renal cysts are associated with progressive renal impairment. It may present with chronic renal failure or be found during screening of relatives of patients with the disease. More unusually it can present with an abdominal mass, with hypertension or with rupture of an associated intra-cranial Berry aneurysm...

Examine the cranial nerves

Test the sense of smell in each nostril. Test visual fields, examine for blind spot. Examine pupils and test direct and consensual reactions to light and accommodation. III, IV, VI Oculomotor, trochlear and abducens Look for ptosis drooping of the eyelid s . Examine eye movements and look for nystagmus. Enquire about any double vision. Examine facial sensation to light touch and pinprick. Examine power of masseters and temporalis 'clench teeth, open your mouth and stop me closing it' . Test...

Change in bowel habit

A change in bowel habit represents an important symptom as it may be due to a GI lesion, such as a rectal carcinoma, an adenomatous polyp or be due to malabsorption. However, a change in bowel habit can occur in benign conditions, such as irritable bowel syndrome. Vomiting, diarrhoea and change in bowel habit 63 Table 28.1 The differential diagnosis of vomiting. e.g. with alcohol Bowel obstruction Dehydration Abdominal tenderness Drowsy Dehydration Abdominal distension Tinkling bowel sounds...

Mouth and throat

Inspect with aid of torch and tongue depressor. Look for angular cheilitis, telangectasia, pigmentation, wasting or fasciculation of tongue. Ask the patient to stick his her tongue out and touch the roof of his her mouth. Inspect the gums and teeth for caries. Consider the possibility of dental abscess. Look for tonsils, uvula and posterior wall. Ask the patient to say 'aah'. Is there any inflammation, exudates, enlargement or growths Palpate any visible abnormalities with a gloved finger.