CLINICAL METHODS

By Joram K. Ngigi
March 2024 class
 Aims of Clinical Methods
• A student should learn the art of taking detailed
informative history. A good history is an important
aspect of medicine.
• Both the important positive and important negative
physical signs should be noted so as to reach a
conclusion.
• Clinical methods are acquired by a combination of study
and experience
• There is always something new to learn
CONT’
It requires:
• Knowledge of disease and its patterns of presentation
• Ability to interpret a patient's symptoms and signs
 Patient – Doctor Relationship
• It is essential that both patient and clinician feel at ease,
neither feels threatened by the encounter
• Does the patient smile, or appear anxious?
• Do they make good eye contact?
• Are they frightened or depressed?
• Are posture and stance normal?
• Is the patient short of breath, or wheezing?
• Students/clinicians need to approach patients not as
“cases” or “diseases”, but as individuals whose
problems/symptoms are to be heard empathetically.
 Skills in History Taking
• It is vital for the doctor to steer and mould the process
• Ensures information gathered is complete, coherent and, logical
• It is very important to use words the patient will understand and use appropriately
• During any consultation non-verbal communication is as important as what the
patient says
• The history of a patient should contain all the facts of medical significance in the
life of a patient
• The history should be recorded in a chronological order, and recent events should
be given most attention.
• Allow the patients to narrate his/her history in his/her own way and language
without any interruption.
• Physicians/clinicians should be careful not to suggest the answers to the questions
being posed.
• NB: History taking is not a mere records of some
questions and answers between the doctor and the
patient, listen to the patient, he/she is telling you the
diagnosis.
 History Techniques
• If a patient gives a positive response it leads to further questioning
e.g.
• Headache – which part, when, always on/off etc, while a negative
response moves the clinician on the next question
• Technical words should be avoided , the patient need to understand
what is being asked/said
• Remember the public/lay men are increasingly aware of medical
terms or medical matters through the internet and mass media, but
this does not necessarily mean they understand the terms
• Therefore certain terms having different meaning may be clarified if
used by the patient
 Types of Enquires/Questions
1) Open ended questions:- they do not exclude any answer category. They give minimal
structure and direction to the answer so that the client has the freedom to answer in his/ her
own way.
• Examples
• Tell me about yourself, What year were you born?
• When you are unable to sleep, what are you thinking about?
2) Closed ended questions:- they provide limited options for answers which are often
short(yes or no). They are easily suggestive/leading
• Example
• Was the discharge smelling
• Is the abdominal pain on the right or the left
4) PROBING- This is whereby you try to encourage the patient to give more specific
information e.g what happened next, how did it make you feel.
GENERAL HISTORY TAKING

• This is an important component of medical and health

care practice because it is what provides the necessary
information and the relevant details for making of a
diagnosis and subsequently the decision on patient
management.
Requirements
• A quiet and conducive consultation room.
• Table, chair, examination couch.
• Writing materials
• An interpreter/ informant
• Chaperone; is a person who acts as a witness for a patient
and a health professional during a medical examination or
procedure.
 Procedure for history taking
• Welcome the patient(greet) and ensure his or her comfort(offer a seat/ the couch)
• Introduce yourself
• Assure confidentiality
• Establish the language of communication
• Conduct the interview using relevant communication skills.
• Quick assessment of the patient
Does the patient smile, or appear furtive or anxious?
Does the patient make good eye contact?
Is he frightened or depressed?
Are posture and stance normal?
Is he short of breath, or wheezing?
• Note taking is important during consultations while being able to see the patient and establish
eye contact. Show empathy and awareness of his needs during the discussion of symptoms,
much of which may be distressing or even embarrassing.
 Challenges in History Taking
• Anger/hostility
• Intoxicated patients
• Handling depressed cases
• Sexually attractive or seductive patients
• Confusing behavior /histories
• Limited intelligence interfering with recall
• Development disabilities, mental retardation
• Communication barriers – due to language social, cultural, religion
differences, sight , speech, hearing impairments
• Unconscious patients- clinician not able to get facts relating to the illness.
 AIM OF HISTORY TAKING
• To understand patients owns perception of their
problem and to start or complete the diagnosis
process. This requires knowledge of disease pattern
and ability to interpret patients signs and symptoms.
• Symptoms: what a patient complains of ie sinus
pain
• Signs: what you find on examination of the patient.
ie running nose.
History taking
Components of history taking
(1) Patients Particulars (Biodata)
• Date & time- for medical records, administrative and legal purposes, to judge
and determine the progress of patient who are admitted in the ward.
• 3 names (to avoid confusion, coincidence of names, mistaken identity)
• Exact age (for admission purposes, making diagnosis, prescription purposes)
• Sex/gender (to decide the ward for admission, for making diagnosis)
• Inpatient/outpatient number (for record keeping, for identification
purposes)
• Occupation (some conditions are related to a person’s occupation),
• Marital status
History taking
Components of history taking cont….
• Religion ((religious believes have dimensions on management, the religion could
have contributed to the disease, some religion forbids some form of treatment- blood
transfusion)
• Address and residence (including telephone contacts, physical address i.e. the
village, sub-location, location, county. Helps to identify common diseases in certain
areas- epidemic diseases, for patient follow-up or home visits. For tracing relatives
and next of kin incase of death or abscondement for legal and medical purposes
• Informant (this is the person who gives information or history of the patient on
behalf of the patient/if the patient is not able to speak- very ill/children/patients who
are in coma. The information can be given by a parent, relative, friend, neighbour,
colleague, policeman. In case of a child, the best informant would be the
mother/caretaker.
• Next of kin (important to trace relatives in case of death or abscondement, for legal
and medical purposes)
History taking
Components of history taking cont….
(2)Chief Complain (CC)
• Main complaints for which the patient is seeking medical attention and the duration, this is the
patient’s chief symptom(s) in their own words e.g. haemoptysis vs. coughing up blood.
• Ask the patient an open ended question such as “what is your problem today”? “What brought
you to hospital today?”
• The complaints may be one, two or more. All should be recorded in a chronological order.
• Always seek clarification of the patients symptoms
Headache on and off x 2/12
Difficulty in breathing x 1/52
Chest pain x 1/7
• The duration of a complaint may be difficult especially in elderly patients or in uneducated
patients. In such situations, approximate duration may be asked.
• NB: Make every attempt to use /quote the patient own words e.g. what is your main complaint
and when were you last in your usual state of health.
History taking
Components of history taking cont…
(3) History of the Presenting Illness (HPI)
• Ask the patient to tell the detailed story of his/her illness from the day it started
till that day he/she has sought medical attention.
• Patient should not be interrupted while narrating the history
• Ask about and document the details of the presenting complaint, nature of the
problem, how it started.
• For each symptom determine;
• The exact nature of symptom
• The onset- the time/date it began (suddenly/gradually), if longstanding, why is the
patient seeking help now?
History taking
Components of history taking cont…
• If the patients describes the complaints in medical terms rheumatism/arthritis
(to mean joint pains), malaria (to mean chills/rigors), migraine (to mean
headache), then he /she should be asked to tell what actually happens during
these complaints.
• Periodicity and frequency- is the symptom constant or intermittent
• Change of the symptom over time- is it improving or deteriorating over time
• Exacerbating factors- what makes the symptom worse
• Relieving factors- what makes the symptom better
• Any other associated symptom
• Clinician should enquire about each and every complaints presented by the
patient.
History taking
Components of history taking cont…
For example: Analysis of a complaint / symptoms
• The most common complaint that brings the patient to hospital is pain. Ask
about the following in relation to pain.
• Site- where exactly is the pain, ask the patient to point to the site with one
finger
• Onset- mode and rate of onset, how did it start, over how long (the duration)?
• Radiation- is the pain static or moves from one place to another?
• Character- is the pain dull, aching, stabbing or burning?
History taking
Components of history taking cont…
• Severity – how severe is the pain does it interfere with his/her daily
activities? Pain is scored out of 10 (0-10). (pt ,ay indicate pain levels verbally
or mark simple scales, the numerical rating scales is commonly used,frm 0-
10 zero mean no pain
• Timing- is there specific time when patient experiences this pain, is it on
/off?
• Exaggeration- what brings about the pain, what makes the pain worse?
• Relief – what relief the pain, what makes it better e.g. change in position,
rest, food, defecation or passage of wind.
• Other associated symptoms- is the pain associated with other symptoms
e.g. nausea, vomiting, dyspepsia, shortness of breath etc
Analyzing pain severity
 Cont’
• NB: It is important to include important positives
and important negatives while recording the history
because this will help in making diagnosis and to
exclude other similar conditions e.g. hypertensive
with headache, blurring of vision but has no swollen
lower limbs no orthopnoea, dyspnoea on exertion.
(4) Review of systems
• Inquire about symptoms in other systems not
represented in the chief complain.
• Perform a brief screen of the other bodily systems
• Finding symptoms that the patient had forgotten
• Identifying secondary, unrelated, problems that can be
addressed
(a) Respiratory system
• Ask whether the patient has cough- If present, is it dry or productive, at what time
is it worst, is it associated with pain, what quantity?
• The colour of sputum, oduor and consistency, is it blood stained (haemoptysis)?
• Ask about dyspnoea- Is the patient- dyspnoeic, does dyspnoea occur in paroxysm,
does the dyspnoea occur at rest or after exercise, what sort of activities provokes
dyspnoea e.g. walking upstairs?
• Ask about wheezing– When does wheezing occur, is it constant or intermittent, is
it provoked by anything e.g. dust, pollen, strong smells, is wheezing worse at
particular time of the day or night?
• Ask about chest pain- What is the exact site i.e. central or peripheral is it
aggravated by deep breathing or coughing, is it acute in onset?
• Ask about haemoptysis (blood in sputum) - If present, how often does it occur
and for how long, is the blood seen alone, or is it accompanied by purulent sputum?
(b) Cardiovascular System.
• Ask about dyspnoea (shortness of breath)- when does it occur –at rest or on
exertion what degree of exertion is necessary to produce it, are there attacks of
shortness of breath at night (paroxysmal nocturnal dyspnoea-PND), does the
patient have dyspnoea while lying flat (orthopnoea)?
• Ask about chest pain/ tightness/discomfort- what is its exact site, what is its
character-dull, severe, stabbing, tearing etc?
• Is there any radiation of the pain to the left arm, neck, shoulder or what
precipitates it, what relieves it, is the pain present at rest or during exertion, is
the pain relieved by rest?
• Ask about palpitations- (awareness of heart beats) what brings palpitations
and how long does it last?
• Is it paroxysmal or intermittent, it is induced or relieved by exercises?
• Is the heart beats regular/irregular and whether patient experience any
missing of heart beat?
• Ask about cramp-like pains in the calves when walking relieved by rest.
• Ask about ankle swelling- does the patient have ankle or leg swelling the
duration, when is the swelling worse (day/night) are the clothes or shoes
tight?
• Ask about cough-as in respiratory system.
• Ask about bluish coloration of extremities (cyanosis) is there coldness
or redness of the extremities.
(C) Gastro-intestinal system
• Ask about abdominal pain- the exact site of the pain lower/upper abdominal, how
severe is it, is it continuous or intermittent, does it radiate to any other site or direction?
• What is the duration of the pain, is the pain related to meals?
• What are the aggravating factors, what are the relieving factors- food, vomiting,
defecation, medication, passage of flatus?
• Ask about appetite –is it reduced or increased, if reduced, is the appetite poor or the
patient is afraid of taking foods due to pain?
• Ask about vomiting- what is the frequency (how many times in 24hrs)?
• What is the colour of the vomitus, does the vomitus contain blood, residues of food taken,
does vomiting relieve abdominal pain, when does it occur –day or night morning or
evening.
• Ask about flatulent dyspepsia – does the patient experience wind moving upwards or
downwards, does either relieve symptoms?
 Cont’
• Ask about water brash- does the patient get excessive secretion of saliva
into the mouth?
• Ask about heartburn –does the patient feel any pain or burning sensation
behind the sternum, is the pain associated with lying down or sitting up?
• Ask about dysphagia- is there difficulty in swallowing, is it worse with
solids or liquids, is swallowing painful ,is there other associated symptoms
e.g. vomiting?
• Ask about sour eructations- does the patient experience acidic taste in the
mouth, does it have any relation to a specific type of food, does it occur
during lying down, is there any receiving factors?
• Ask about diarrhea- the frequency (times in 24 hrs), what is the duration of
diarrhea, is the diarrhea related to meals or to special foods what is the colour
of the stools?
• Are stool formed, (solid) or unformed liquid or porridge – like, frothy or
watery, has the patient ever passed any blood, is there incontinence of
stool (involuntary passage of stool), any other associated symptoms?
• Ask about constipation- what is the patient usual bowel habit, is there
any change in this habit, if yes, then is the change related to change in
diet, medications etc. is there any colicky pain, is there blood in stool?
• Ask about abdominal distension- is there any increase in abdominal
girth, is there associated flatulence or dyspepsia, is the distension
associated with meal; does the patient have diarrhea or constipation?
(d) Central Nervous system
Ask about headache
• Which part, when, always on/off?
• Is it intermittent or continuous?
• Is it associated with visual disturbance or not?
• Is the headache unilateral, frontal or generalized?
• Is the headache induced by stress (tension headache)?
• Is it radiating to other part(s) etc?
• What relieves the headache?
 Cont’
Ask about dizziness
• Is it intermittent?
• Does it relate to change in head position?
• Is there history of deafness?
• Is there history of trauma or any infections?
• When does it become worse?
• Are there other associated symptoms such as ataxia (lack of
voluntary coordination of muscle movements), speech disturbance,
double vision, facial weakness?
 Cont’
Ask about convulsions/Fits
• Are they generalized or focal?
• From where do they begin and end?
• Does the patient fall?
• Has the patient ever hurt him/herself?
• Does he/she bite the tongue?
• Does the patient micturate or defaecate during the fit?
• Are there any after symptoms (post-ictal symptoms) - automatism,
sleep, headache, paralysis?
• Is there any mental disturbance associated with it?
 Cont’
• Ask about weakness/paralysis- reduction in normal power of
one or more muscles. “Plegia” means weakness that is severe
and complete while “Paresis” means partial weakness. “Hemi”-
one half of the body, “para” refer to both the lower limbs and
“quadri” refers to all the four limbs.
 Cont’
Enquire about paralysis/weakness
• Is there inability to move the limb, part of the body or any side of the
body?
• Did the weakness start slowly/gradually or suddenly?
• Is it stationary or has progressed, if yes, how it progressed?
• Which part of the body is involved?
• What movements are affected?
• Is there difficulty in combing the hair, trying to reach high shelves or
difficulty in getting out of a chair or taking a high step?
• Does the weakness increase with effort and improve after rest?
• Are there any associated sensory or other symptoms?
 Cont’
• Ask about tingling sensation
• Tremors
• Fainting episodes
• Black-outs
• NB: (i) Vertigo- is an illusory/hallucinatory sense of self or environmental
movement most commonly due to a disturbance in the vestibular system.( the
sensation that you or the environment around you is moving or spinning, this makes
it difficult for a pt to keep the balance or carry on daily tasks)
• (ii) Dizziness- is a common symptom that patient use to describe a variety
of sensations such as light-headedness, faintness, spinning.
• (iii) Syncope- is loss of postural tone, inability to maintain erect posture
followed by unconsciousness. It is a symptom resulting from reduced
cerebral perfusion.
 Cont’
• Ask about stroke (sudden onset of neurological difficult i.e.
weakness, sensory loss, or visual disturbance on one side of the
body)
• This may recover in few minutes or less than 24 hours
(transient ischaemic attack- TIA) or may resolve in
neurological deficit (reversible ischaemic neurological deficit-
RIND) or may recover incompletely (stroke), was headache,
vomiting associated with the cerebrovascular disease e.g.
hypertension, heavy smoking, diabetes or hyperlipidaemia, or a
positive family history of heart disease especially vascular
diseases.
 Cont’
Ask about epilepsy- causing seizures consists of repetitive, even stereotype convulsive events.
• What was the age of the first attack, describe the first attack?
• How frequent do these attacks occur, what is the shortest and longest interval between
the attacks?
• Do they occur at night during sleep, is there any aura or warning what is the nature of the
aura during attack (complete partial) seizure) or not (simple partial seizure)?
• Does the patient bite the tongue during the attack? ( if yes examine for tongue injury)
• Does the patient have incontinence (involuntary passage of stool and urine) during the
attack?
• Is there post-ictal phenomenon e.g. headache, somnolence, automatism or Todd’s
paralysis?
• Is the patient on treatment? –take the treatment history.
• Ask about predisposing or precipitating events e.g. infection, brain injury, fever and
family history.
The end
 (e) Musculoskeletal System
• Is there pain/swelling or stiffness in joint(s)?
• Is the pain constant or episodic?
• Are there any recurrent attacks of joint pains?
• Does the joint pain moves from one joint to another (migratory joint pains
of rheumatic fever and gonococcal arthritis)
• What is the distribution of the joint pains i.e. whether it involves small
joints (rheumatoid arthritis) or large joints (osteoarthritis)?
• Is the joint visibly swollen?
• Is there any family history of gout or other rheumatic disorders?
 (e) Musculoskeletal System cont…..
• Is there any gait/posture abnormality?
• Are there soft tissue symptoms such as pain, tenderness and
swelling?
• If present, what is the site of these symptoms?
• Is there any history of trauma or overuse during sports?
• Are there symptoms of bone disease e.g. fracture, dislocation,
deformity, pain, swellings?
• If yes, is there any history of trauma or stress?
• Is there congenital or family history of bone disorder?
 (f) Genito-urinary system
• Is the urine altered in amount?
• Is the stream of urine normal or reduced in flow?
• Is urine altered in colour, is it clear/turbid when passed?
• Is the blood in urine (haematuria), if yes, at what period of micturation?
• Is there increased micturation frequency during the day (polyuria) or night
(nocturia)?
• Is the frequency associated with undue thirst?
• Is there pain during micturation (dysuria)? If present, is it before, during or
after micturation?
 (f) Genito-urinary system cont…
• What is the character of the pain and where is it felt?
• Male patient- is there any urethral discharge, swelling of scrotum?
• If there is discharge, when does it occur, i.e. at the initiation or end of
micturation?
• Is there any history of contact with other woman/women other than the wife?
• Female patient- is there vaginal discharge (same as in males)?
• Are there any menstrual problems?
• Enquire about sexual functional complaints e.g. impotence, premature
ejaculation, infertility, anxiety about masturbation or homosexuality.
(5)Past medical and Surgical History
• Any previous/past history should be asked.
• This must be verified by asking what actually happened during that illness which made him/her
to be admitted – when was it, which hospital , for how long, what treatment was given, what
was the outcome….
• Relevant past history pertaining to the present symptoms should be asked e.g. acute rheumatic
fever in cases in cases with rheumatic heart disease, jaundice in the past in case of liver diseases.
• Patient with diabetic (not curable) thus ask about age of onset, its progression, drugs used, any
complications in the past, adherence to drugs
• Childhood illnesses e.g. measles, rubella mumps, whooping cough, chickenpox, rheumatic fever,
polio is relevant.
• Adult medical illness e.g. diabetes, hypertension, Tuberculosis, asthma, hepatitis, HIV diseases
must be asked ( menstruation history , birth control, sexual function) carry significance in female
presenting with gynaecological complaints
• NB: The patient should narrate the history himself/herself unless otherwise indicate.
(6) Drug History
• List all the medication the patient is taking, including the dose and
frequency
• The patient may not consider some medications to be drugs:
• Eye/ear drops.
• Inhalers.
• Sleeping pills.
• Oral contraception.
• Over the counter drugs
• Herbal remedies.
(7) Personal , Social & Economic History
• Ask about the exact nature of work occupation, former
occupation if any. Ask about domestic and marital relations in
both males and females; ask about marital status,
homosexuality is common in single men.
• Ask about the type of housing owned or rented the patient
lives in – permanent, semi –permanent, temporary housing,
ventilation
• Ask about sanitary conditions disposal (pit, bush etc)
• Ask about education level
Smoking & Alcohol Use
• Ask about social habits i.e. smoking, alcohol drinking, any drug abuse which is
contributes to some diseases
• In smoking determine the pack years i.e. the number of sticks taken divide by
20 times the number of years smoked
• If patient is an ex-smoker, note the length of time since the patient stopped
smoking or taking alcohol
• Should attempt to quantify.
• Remember to ask about passive smoking
• Patient may be trying to please you/ feel embarrassed about openly admitting
their true consumption
• Beware of appearing judgmental
Do CAGE Assessment for alcohol dependency
• NB: Some patient may deny history of drug abuse, firm and persistent to get
full information either from the patient or from a relative, staining on fingers
or teeth should raise strong suspicion that patient is or until recently was a
heavy smoker.

(Read about CAGE assessment)- Assignment

(8) Family history
• Note the patient’s position in the family, the ages of the siblings and their
health, status of the parents (alive/dead), if dead the cause of death if
known
• Ask about any diagnosed condition in other living family members
• Important illness, age and causes of death of immediate relatives, ask
about any known familiar/hereditary disease (haemophilia, SCD) and
chronic diseases (diabetes, hypertension coronary artery disease, renal
diseases, hyperlipidaemia) cancer & the specific type of cancer, asthma,
arthritis, mental illness, epilepsy, allergies etc.
• Status of parents –whether alive or dead if dead , the cause of death (if
known)
9) Gynae History taking to the females- Enquire about
LMP, the flow of the menses( if heavy or light, number
of pads used in a day, colour, etc) menarch.
10) Summarizing a case
Purpose of the summary- provides sufficient information to
understand the factors which led to the present illness, something
of the person in whom the illness is found, and sufficient detail of
history, clinical findings and special investigations for the
reasoning behind your diagnosis to be appreciated. This is
described in detail below. However, it is frequently necessary to
describe a patient’s problems in outline only, without formally
presenting the case.
 Cont’
Important points to remember;
• For a summary, make sure that every point you make is a
vital point; do not be tempted to rehash the whole
presentation. Make sure the few points you choose to give
are stated in a logical order; i.e. beginning with the factors
which underlie the current illness, proceeding to the details
of that current illness, and followed by subsequent course
and plans. For a summary, brevity( concise/exact use of
words) is vital. Your summary should not require more than
4 or 5 sentences.
11) General examination
• It is assumed that you clinicians/physicians will
act with professionalism, integrity, honesty, and
with respect for the dignity and privacy of
your patients
• Chaperone should be present during any intimate
examination- ideally be the same gender as the
patient
• The right approach
• One important rule is that you should always stand at the patient's right hand side.
• This gives them a feeling of control over the situation (most people are right
handed)
• All the standard examination techniques are formulated with this orientation in mind
• The general examination starts as soon as the patient enters the examination room.
The physician should always try to assess the patient’s general appearance which
include demeanour, personal cleanliness/hygiene and the nature and status of
clothing
• Use all senses well (sight,hearing,tactile,smell etc)
• A good general examination requires a co-operative patient and a quiet, warm and
well lit room. Day light is better than artificial light, which may mask changes in
skin colour e.g. the faint yellow tinge of slight jaundice.
Cont’
• Every attempt should be made to reassure and relax the patient
• A chaperone should always be present when a male physician/clinician
is examining a female patient and vice versa and during rectal and
vaginal examination- both to reassure the patient and to protect the
physician from subsequent accusations of improper conduct
• Expose appropriately
• Start the examination in a manner that will appear relevant to the patient
e.g. a patient presenting with cough, chest pains, start with examination

of the chest (affected system)

Instruments required in examination of patients.
• Stethescope (used in auscultating the chest)
• Opthalmoscope ( used to detect and evaluate symptoms of retinal detachment or eye diseases such as
glaucoma)
• Otoscope (help visualize and examine the condition of the ear canal and eardrum.)
• Nasal speculum
• Tuning fork
• Percussion(reflex) hammer
• Tape measure
• Pen touch (pen light)
• Sphygmomanometer – BP Machine
• Thermometer
• Watch
• Snellens chart
• Wooden spatula
 Cont’
Observation at glance/First impressions
• Is the patient comfortable or distressed?
• Is the patient well (fair general condition) or ill (sick looking)?
• Is there a recognizable syndrome or facies?
• Is the patient well nourished and hydrated?
• Bed-side clues
• Additional clues as to the patient's state of health in the objects around them
• Examples: Oxygen tubing, inhalers, insulin injections, glucose meter, or cigarettes
• Observe facial appearance of the patient, the built, complexion, state of clothing.
Example a startle look is seen in Grave’s disease, apathy or blunt expression is seen
in depression, agitation is indicates hypomania, toxic look with swinging
temperatures indicate septicaemia or toxaemia.
• NB: The recognition of looks of pain, fear, anxiety and grief alerts the clinician to
explore the possibility of underlying psychiatric disorder.
 Cont’
• State of clothing and personal hygiene- inspection of clothing gives information
about personality and state of mind. Patients with dementia are shabbily dressed and
may have soiling of underwear.
• Excessive clothing may reflect the cold intolerance of hypothyroidism, or to hide skin
rash/disease or needle marks.
• Mental state/consciousness- is the patient conscious? Patient’s conscious level should
be assessed (GCS).
• Note whether the patient is co-operative and answers your questions or non-
cooperative and avoids or overlooks your question.
• Posture/Gait and abnormal movements- observe the gait of the patient while getting
into the examination room this may give a valuable information e.g. patients with
congestive cardiac failure may sit up on the bed due to orthopnoea, patients with
asthma are dyspnoeic at rest, patients with colics are restless and will toss themselves
in bed in agony, patients with neurological disorders produce a characteristic posture
e.g. neck retraction in meningitis, opisthotonus in Tetanus
• Sound/voice/speech- normal speech is produced by coordination of
the tongue, lips, palate, nose and voice box in the larynx. Some non-
neurological causes may produce disturbances in speech such as cleft
palate, nasal obstruction, loose denture and dryness of the mouth.
• Hoarseness of voice may be due to local causes (Laryngitis) or a
neurological disorder.
• Some other sound may help in diagnosis e.g. wheezing, rattling or
stridor help in differentiation of dyspnoea.
 Cont’
• Sounds during cough may be characteristic of some disorders such as whooping cough which is
suggestive of Pertussis, brassy cough indicate bronchial obstruction (adenoma), barking cough
suggests tracheobronchitis
• Smell/Odour- normal smell or odour from the body is due to sweat. Pungent smell may be due to
excessive sweating and poor personal hygiene.
• Malodour (odour of dirty and soiled clothing and smell of dried-out urine) occurs in elderly or
physically disabled /bed ridden patients or those with dementia.
• Offensive/faecal smell from the body occurs in gastrocolic fistula.
• Halitosis means malodorous breath which often goes unrecognized by the patient but is offensive to
others.
Causes of Halitosis
• Malodorous breath (halitosis)- Bronchiectasis, lung abscess, oral sepsis (stomatitis, gingivitis),
extensive carries, atrophic rhinitis, smoking and idiopathic.
• A fishy odour (fetor hepaticus)- hepatic failure
• Ammonical or urinary smell- uraemia, azotaemia
• Sweet or fruity oduor- diabetic or starvation ketoacidosis
•
Example
• On general examination, the patient is fully conscious, cooperative, well
oriented in time, person and place, and lying/sitting comfortably in bed.
He/she is having a normal built, physical appearance and maintaining good
personal hygiene. He is well nourished and well hydrated. He/she is not
pale, not cyanosed, not jaundiced, not dehydrated, has no finger clubbing
and has no lymphadenopathy.
• The vitals- BP…………, PR…................ RR…………….. and
T………………are within normal ranges.
Examination of general parameters

(1) Examine for Pallor

• When Inspecting the appropriate is the conjunctiva, nail
beds, tongue and palms for changes of the skin.
• Peripheral vasoconstriction or poor blood flow causes skin
and conjunctival pallor, even in the absence of blood loss
• Facial pallor is often a sign of severe anaemia
(2) Examine for Cyanosis

• Cyanosis refers to a bluish discoloration of the skin and

mucous membranes, produced by presence of reduced
haemoglobin in the blood either locally as in impaired
peripheral circulation or generally, when oxygenation of
the blood is defective.
Cont’
• Cyanosis occur due to reduction in blood supply or a
slowing of the peripheral circulation.
• Arises through exposure to cold, reduced cardiac
output or peripheral vascular disease.
• One cannot have central cyanosis without
demonstrating peripheral cyanosis, but peripheral
cyanosis can occur alone
 Types of Cyanosis
a) Central cyanosis- results from imperfect oxygenation of blood, as seen in heart
failure and some lung disease or from mixture of desaturated venous blood with
arterial blood due to right to left (venous-arterial) shunt in the heart.
• In this case the cyanosis is general and characteristically affects the tongue, lips,
which appear blue as well as the limbs. The cyanosed extremities are warm.
• Sites of examining central cyanosis- below the tongue(frenulum) lips, tip of the
nose.
b) Peripheral cyanosis- is due to excessive reduction of Oxyhaemoglobin in the
capillaries when the flow of blood is slowed. This happens due to exposure to
cold, when there is venous obstruction or in heart failure. The cyanosed
extremities (toes, fingers) appear blue and are cold, the tongue is unaffected.
• Cyanosis of heart failure is often due to both central and peripheral causes. Carbon
monoxide poisoning produces a generalized cherry-red discolouration, due to the
presence of carboxyhaemoglobin
3) Examine for Jaundice
• Jaundice is yellow pigmentation/discolouration of those
tissues in the body which contain elastin (skin, sclera, sores
of feet, and mucosa that is lips) Occurs due to an increase in
plasma bilirubin (visible at >35µmol/L or ≥ 2.5mg %) The
level of bilirubin < 2.5mg % produce sub-clinical jaundice
which may not be detected.
 Causes of Jaundice
a) Pre- Hepatic Cause- Jaundice result from increased breakdown of red blood cells
leading to increased serum bilirubin
• Congenital red blood cells casing abnormal shape e.g. in SCD, hereditary
Spherocytosis, hereditary elliptocytosis
• Enzyme deficiency- Glucose 6 phosphate dehydrogenase (G6PD) deficiency),
pyruvate kinase deficiency
• Haemoglobin abnormalities- Thalassaemia
• Auto-immune haemolytic anaemia
• Drugs- Penicillins
• Infections- Malaria
• Mechanical- DIC
• Transfusion reactions
• Paroxysmal nocturnal haemoglobinuria
 Cont’
b) Hepatic Causes- there is disorders of uptake, conjugation and
secretion
• Viruses- Hepatitis A, Hepatitis B, Hepatitis C, Epstein Barr virus
(EBV)
• Alcohol
• Autoimmune disorders
• Drugs- Isoniazid, Rifampicin, Acetaminophen, Penicillins, oral
contraceptives, Chlorpromazine
• Liver malignancies- primary or secondary metastatic tumours
• Cholestasis
 Cont’
C) Post-Hepatic causes- results from obstruction to elimination of bilirubin
• Gallstones
• Inflammation of the gall bladder
• Gall bladder cancer
• Pancreatitis
• Cancer of pancreas
• Bilary tree obstruction from gall stones, compression from pancreatitis,
pancreatic tumour, lymphn nodes, biliary atresia
• Cholangiocarcinoma
• Post-operative stricture
• Primary sclerosing cholangitis
4) Examine for Hydration/dehydration Status
• Mucous membranes- dry mucus membrane,inspect the tongue and mucous
membranes for moisture
• Skin turgor/skin elasticity- demonstrated by pinching up a fold of skin and
then released. It remains as a ridge and subsides slowly if skin elasticity is lost,
otherwise it returns immediately to its normal position.
Loss of elasticity is not a true index of hydration as it is lost in old age and due
to loss of collagen in the skin.
• Sunken anterior fontanel in infants indicates dehydration- we have 2 types
of fontanelles i.e anterior and posterior fontanelle. Anterior fontanelle closes at
age of between 9- 18 months and posterior fontanelle closes at the age of
between 1-2 months .
• Sunken orbits; the eyeballs are soft and sunken
Cont;
Causes of Dehydration
• Gastrointestinal loss- diarrhoea, vomiting,
gastroenteritis (food poisoning)
• Cutaneous loss- burns, perspiration (excess sweating)
Checking for dehydration
5) Examine for Oedema
• Oedema refers to fluid accumulation in the subcutaneous tissues.
• Check for ankle and sacral oedema( common in bed ridden patients).
• Compress on a skin over bony area for 10 seconds( ankle joint at the
medial malleolus_2cm above the ankle joint, dorsum oedema and
sacral oedema)
• Oedema can be reported as either, tender or non-tender, pitting or
non-pitting. Or localized or generalized or Anasarca common in
CCF/CKD pts.
• Areas to check for oedema includes- lower extremities( ankle
joint,boby portion of tibia,dorsum of the foot) and sacrum.
Classification of oedema and causes
1) Localized:-involving limb or 3) Special:
organ Involving the pulmonary and the cerebral.
 Lymphatic edema 4) Intracellular
 Inflammatory oedema • Malnutrition
 Toxic Allergic Oedema • Poor metabolism
• Inflammation
2) Generalised( Anasarca or dropsy)
5) Extracellular
• Renal edema  Heart failure
• Cardiac edema  Renal disease
• Nutritional oedema  Low plasma proteins
 Lymphatic obstruction.
Types of OEDEMA
• Peripheral edema- this affects the feet, ankles, legs
extending to the sacrum.
• Pulmonary oedema- This occurs when excess fluid collects
in the lungs making breathing difficult.
• Cerebral oedema- This occurs in brain
• Macular edema- This is a serious complication of diabetic
retinopathy.
Some common causes of oedema
• Congestive heart failure
• Cirrhosis
• Kidney disease
• Kidney damage
• Severe,long-term protein deficiency
• Venous insufficiency
• Pregnancy
• Inadequate lymphatic system.
NB:-Read and make a paragraph on grading od edema
Grading pitting oedema
6) Examine for Lymphadenopathy

• Lymphadenopathy is the enlargement of lymph nodes.

• In health patients, palpable glands can be detected especially in
the axilla and the groin. They are usually less than 1cm in
diameter; lymph nodes greater than 2cm in groin are considered
abnormal and pathological
 Important groups of lymph nodes includes:

• Pre-auricular- in front of the ear

• Post-auricular (posterior auricular)- superficial to the mastoid process behind
the ear.
• Occipital- below the occiput at the base of the skull.
• Tonsilar- at the angle of the mandible
• Submandibular- midway between the angle and the tip of the mandible
• Submental- in the midline, a few centimeters behind the tip of the mandible
• Superficial cervical- superficial to sternocleidomastoid
Important groups of lymph nodes includes
cont…
• Posterior cervical- along the anterior of the trapezius
• Deep cervical- lymph node chain deep to the sternocleidomastoid and
often inaccessible to examination
• Supraclavicular- deep to the angle formed by the clavicle and
sternocleidomastoid
• Axillary- 5 groups i.e. lateral group, central group, apical group,
pectoral group and subscapular group
• Inguinal and femoral lymph nodes- horizontal and vertical groups
• Popliteal lymphnodes- behind the knee
Reporting following lymph nodes examination
• Site: Acute and chronic infections and metastatic carcinoma will cause localized
lymphadenopathy
• Number: how many nodes are enlarged?
• Size: normal nodes are not palpable. Palpable nodes therefore are enlarged. Measure their
length and width
• Consistency: malignant lymph nodes feel firm or hard and irregular.
• Enlarged nodes secondary to infection may feel rubbery
• Tenderness: painful, tender nodes usually imply infection.
• Fixation: nodes that are fixed to surrounding tissue are highly suspicious of malignancy.
• Matted glands may occur in tuberculous lymphadenopathy.
• Overlying skin: inflamed nodes may cause redness and swelling in the overlying skin.
• Spread of a metastatic carcinoma into the surrounding tissue may cause oedema and
surface texture changes
7) Examine for Finger Clubbing
• Early clubbing: softening of the nail bed but this is very
difficult to detect. Progression leads to a loss of the angle at
the base of the nail
• Eventually to gross curvature and deformity
• Clubbing leads to a loss of the diamond-shaped gap
(Schamroth's sign)
Clubbed fingers Examining for Finger clubbing
Examine the Nutritional Status of the patient
• Assessment of nutritional state of a patient is an important part of
clinical examination because nutritional depletion may eventually
result in malnutrition which has its functional consequences such as
reduced immune response, muscle weakness, oedema, confusion,
or neuropathy.
• Examine for wasting or thinness of muscles, oedema, pallor,
weakness, loss of skin elasticity, and other signs of nutrients and
vitamins deficiency are pointers towards poor nutrition or
malnutrition
 Conclusion
• The purpose of each clinical assessment is to establish
reliable data from the history and the physical
examination in order to facilitate diagnosis and plan
treatment
• It is therefore essential that clinical information be
organized in such a way that it can be easily accessed
and utilized