CLINICAL METHODS LECTURE NOTES

DR JUDITH KAMPIRE
 Introduction

The clinical manifestations of disease are:

 Symptoms: Something the patient feels or observe
themselves, which they regard as abnormal, e.g. pain,
vomiting or weakness of a limb.
These are discovered by taking a “history”, which means a
clinical “interrogation” or dialogue between doctor and
patient.
Signs: Physical or functional abnormalities elicited by
physical examination, e.g. tenderness, a swelling felt by
palpation or a change in a tendon reflex.
 The Patient’s problem

Patients go to a doctor because –

they are alarmed by their symptoms and believe themselves to be ill
they seek an explanation of and relief of their symptoms
they want to recover to their previous health as rapidly as possible, by adopting
the treatment advised by their doctor and hope the cure will be a permanent one.
they and their relatives wish to know the probable course and outcome of the
illness, the effectiveness of treatment available and whether any complications
or sequelae will follow the disease.
they need help and guidance in the management of chronic diseases.
they require the interpretation of results.
 Caution:

Patients may be alarmed by use of common phrases that

might be part of a junior student’s differential diagnosis but
are unlikely to apply to the individual being examined.
You should avoid use of words like ‘cancer’ or ‘tumor’ - using
neoplasm or mitotic disease instead.
Other avoidable terms and their suggested replacements
would be AIDS / HIV (‘retroviral infection’), enlarged heart
(‘Cardiomegaly’), enlarged liver (‘hepatomegaly’), leukemia
(‘white cell disorder’).
 The Doctor’s problem

The doctor wants to know the meaning of the patient’s symptoms and of the
signs which are elicited, in order to recognize the disease or diseases from
which the patient is suffering (diagnosis).
Knowledge of the disease and of its course in others allows the doctor to
forecast the outlook (prognosis) and to prescribe treatment (therapy).
 Pre-symptomatic diagnosis:

In many patients the presence of disease may be detected as a result of

population screening, or the targeted population of specific groups.
This is a major role of General Practice in the health care setting and includes,
for example, recording of blood pressure in all registered patients, cervical
screening and breast screening of selected patient groups.
 Diagnosis:

An interpretation of symptoms and signs leading to identification of a disease

(or diseases).
 A complete description involves knowledge of the causation (etiology) and of
the anatomical and functional changes which are present.
It depends on the assembly of all the relevant facts concerning the past and
present history of the illness, together with the condition of the patient, as
shown by a full clinical examination..
 contd

Simple laboratory tests, such as examination of the urine or estimation of the

hemoglobin content of the blood, can be carried out by the doctor himself.

For most patients referred to hospital, more elaborate special investigations are
necessary, such as radiological examination and special biochemical
investigations
 Prognosis: (outcome of an illness):

This depends on the nature of the disease, on its severity and on the stage of
the disease reached in the particular patient.
It also depends on the constitution, occupation and economic status of the
individual patient, as well as his motivation and ability to collaborate in
treatment. may be expressed statistically in terms of percentage chances of
recovery or of death in acute illness, or of average expectation of life in
chronic diseases.
These estimates must be based on experience gained by the study of large
numbers of comparable patients and must be applied with the greatest caution
to individual patients.
 Syndrome:

A syndrome is a combination of symptoms and/or signs which commonly

occur together, e.g. malabsorption syndrome, consisting of chronic diarrhea
with fatty stools and multiple nutritional deficiencies.
 HISTORY TAKING

History taking and physical examination can be a very exhausting experience

for the patient.
For these reasons it is essential, before taking a history or conducting a
physical examination, to ask if the patient feels able and willing to cooperate.
Always be polite, be respectful and be clear. Remember the patient may be
feeling anxious, unwell, embarrassed, scared or in pain.
Always ensure your hands are washed.
You should be gathering information and observing the patient as soon as
you meet them, history taking and examination are, sequential processes,
they are ongoing at the first glance.
Privacy
Ensure that there is privacy ;make sure curtains are properly closed, see if
the examination room is free and comfortable for the patient.
Language
Establish whether they are fluent in the language you intend to use and, if not,
arrange for an interpreter to be present.
Movement of the patient should be restricted as much as possible; for example
when the patient is sitting forward the opportunity should be taken to palpate
the neck, examine the chest posteriorly and look for sacral oedema and spinal
deformity, e.g. kyphosis and scoliosis.
Confidentiality; If you retain a patient history, or submit it as a teaching case,
it must not be identifiable to third parties.
The patient’s confidentiality must be retained. Thus, it is common practice to
use the initials and a Hospital Number.
However, all students should be able to take a full history and examination,
and not to be reliant (or limited) to the use of electronic resources.
NOTE; When meeting a patient, establish their identity (ask for their full
name and confirm ask for their date of birth,address,etc.)and be certain that
any records,notes,test results,etc.refer to that patient.
Often you may wish to shake their hand, `My name is Dr.Ruth and you are...'?
Tell them your name, your title and what you are about to do.
Forexample`Iam Jonathan, a medical student, and I would like to ask you
some questions about your illness if I may'.
 History

1. BIO-DATA.
 N-name
 A-age
 S-sex
 T-tribe
 R-religion
 O-occupation
 N-next of kin
 A-Admission
 D-date of discharge
 E-educational level
 M-marital status
 2. Presenting Complaint(pc)/chief complaint:

PC: The PC should be given briefly in patient’s own words, as far as possible.
For example: “Chest Pain”. Duration: in hours, days, months or years, not
“since ‘Monday” etc. If more than one PC, enumerate in order of importance:
(1); (2); (3)…e.g. headache for 3days.
 3.History of presenting complaint(Hpc)

 Let the patient talk without interruption.

 Record, use and present the patient's actual words
 Great detail about each aspect of the history
 Chronology of complaints
 Focus on the main problems.
 Irrelevant information
General description
The taking of an accurate history is the most difficult and, in the majority of
medical diseases, the most important part of a consultation.
It becomes progressively simpler as the clinician’s knowledge of disease and
experience increases.
The history of the present condition may extend over days, weeks, months or
even years and should be recorded chronologically.
As far as possible, the patient’s own account should be written down,
unaltered by leading questions but phrased in medical terms.
When the patient’s own phraseology is used the words should be written in
inverted commas, e.g. “giddiness”, “wind”, “palpitation” and an attempt
should be made to find out precisely what they mean to the patient.
The order of onset of symptoms is important.
If there is doubt about the date of onset of the disease, the patient should be
asked when he last felt quite well and why he first consulted his doctor.
Dates may be quoted absolutely or relative to the date of writing e.g. five days
ago; but if the latter system is used the date on which the history is written
must be clearly shown.
Notes of any treatment already received and of its effect, if any, must be made.
 4.symptomatic/ systematic enquiry or review of other systems.

After the patient has given a general description of his illness, the system
mainly involved will usually, but by no means always, be obvious.
The patient should then be questioned about the main symptoms produced by
diseases of this system.
This should be followed by enquiries directed towards other systems.
It should be remembered that the classification of symptoms by systems is one
of convenience and is not absolute e.g. breathlessness may arise from disease
of the cardiac, respiratory, renal or central nervous system.
 -Cardiovascular System

a). Breathlessness
on exertion only (noting degree of exertion)
 also at rest, if wakes at night (eg paroxysmal nocturnal dyspnoea, PND)
 duration, severity, precipitating factors, orthopnoea, number of pillows used.
b). Pain in chest
onset - on exertion or at rest, or associated with activity, such as breathing or change in
posture
character - sharp, crushing or “tight”
 site
radiation
duration
exacerbating and relieving factors (e.g. drugs )
 accompanying sensations (e.g. breathlessness, vomiting, cold sweats, pallor, reflux,
heartburn, night sweats, easy fatigability, etc)
 precipitating factors - cold, heavy meal, emotion
c). Oedema
ankle swelling - time of day
 abdominal swelling - tightness of trousers or skirt.
Facial puffiness and the time of the day.
d). Palpitation
patient conscious of irregularity or forcefulness of heart beat
character of palpitation – patients may tap out the rhythm
e). Dizziness
whether associated with change in posture, or palpitation
 whether true vertigo
 whether associated with collapse or loss of consciousness
 faints
f). Peripheral vascular symptoms
 intermittent claudication – pain in the calves or buttocks
on exertion, relieved by rest e.g. in peripheral artery disease.
 Exercise limit, on flat ground and stairs.
 cold feet or hands – association with temperature.
Associated cyanosis, pain or dysesthesia (Raynaud’s
phenomenon).
• rest pain – pain in muscles or feet.
 -Respiratory System

a)Cough
• duration
• character
• productive (of sputum) or not?
• frequency
• causing, or associated with, pain?
• associated with symptoms of infection e.g. fever?
b. Sputum
• quantity
• color
• type (frothy, stringy, sticky)
• when most profuse (during the day, night, the time of year
and the effect of posture)
• presence of blood (haemoptysis) Is the blood red or brown?
(i.e. fresh or old). Streaked with blood/ clots?
• Is it purulent?
c.Breathlessness
• on exercise or at rest
 • exercise limit – on flat, on stairs
• relationship with posture • Diurnal variation.

d.Wheeze • precipitating factors, (cough, fog, emotion, change

of environment, contact with animals or birds, time of year)
Diurnal variation.
e.Pain in chest • site • character • relationship with
respiration (pleuritic)? • relationship with coughing?
f.Hoarseness • change of voice with or without pain •
duration? • site of pain - pharynx or neck “Sore throat”
g.Nasal discharge or obstruction • one or both nostrils •
watery or purulent? • blood (epistaxis), note – may result in
hematemesis if blood swallowed.
h.Loss of weight • time course • appetite: food intake
i.Sweating • day or night • requiring change of clothes? •
associated with other symptoms of infection?
j.Smoking • cigarettes, cigars? • tobacco? • duration
(packets/day x years = PACK YEARS)
k.Occupation • high risk occupations – e.g. mining, farming,
shipyards • type of dust? asbestos? Duration
 Gastrointestinal System

Abdominal pain • duration • character - burning, gnawing,

colicky etc. • site • depth • radiation • frequency –
continuous, periodic, continuous with exacerbations • timing
and association - nocturnal pain (awakening in early hours),
relationship to eating • aggravating and relieving factors –
e.g. food, milk, bowel action, posture • relationship with
micturition, retention of urine, menstrual cycle, menstruation
• remote or referred pain • rectal pain • back pain –
pancreatic, • shoulder tip pain (due to diaphragmatic
irritation) - gall bladder disease, perforation
Appetite • loss of appetite - distaste disturbance for food (anorexia);
“fear” of eating – pain, weight gain (anorexia nervosa) • increased
appetite – obesity, pregnancy, hyperthyroidism.
Difficulty in swallowing (dysphagia). • duration - continuous or
intermittent; progressive • fluids or solids, or both? • painful or
painless? • level at which food “sticks” • nausea - continuous (e.g.
hepatitis, pregnancy, uremia); or intermittent • related to food (type),
e.g. neoplasm, gastritis, gallbladder disease (fatty foods) • related to
posture, e.g. labyrinthitis • vomiting, preceded, or not, by nausea?
(distinguishes gastric from cerebral vomiting, which is not preceded
by nausea) • character - small, repeated, projectile; related to food,
pain, special foods
Vomitus • amount • color – clear, bile stained, coffee
grounds, fresh blood • content - undigested food (e.g. taken
days or many hours before in pyloric obstruction)
Belching • eructation of gas through mouth (aerophagy)
Flatus • passage of gas rectally Flatulence • discomfort
caused by excessive gaseous distension.
Distension • abdominal enlargement causing tightness of
skirt or trousers (due to distension with flatus, fluid, fat, fetus
or feces (5 F’s)) • indigestion • flatulent, painful, regurgitant
Reflux • regurgitation of bitter fluid into mouth which may
be stained with bile or certain food
 Water brash • regurgitation of tasteless or salty fluid to
mouth
Heartburn • burning sensation behind sternum which may
be intermittent; related to posture (reflux); continuous and
prolonged (esophagitis)
Weight loss • usual weight; present weight; amount lost •
over what period; rate of loss • patient may present with
‘loose clothing’
Alteration in bowel habits • enquire into patient’s normal
bowel habits, which may vary in normal individuals from
three times daily to twice weekly.
Constipation • reduction in frequency of defecation as
compared with patient’s normal state, usually accompanied
by hardening of stools • how infrequent? • consistency of
stool? • discomfort or straining? • rectal pain? • constipating
drugs
Diarrhoea • increase in frequency of defaecation, as
compared with patient’s normal frequency - usually
accompanied by looseness of stools which may be liquid or
semi-formed • associated abdominal or rectal pain? • contact
or possible source of infection - specific foods, restaurants,
foreign travel, friends or family members with similar
symptoms, drug ingestion, e.g. antibiotics • spurious -
secondary to severe constipation in elderly (“overflow
diarrhoea”)
Stools • Hard? Small? Pencil shaped? Pellets? • semi-formed
– “ porridgy”, liquid • large, bulky (high fiber diet) • color -
black (melaena, iron, bismuth); clay colored (obstructive
jaundice); yellow (steatorrhoea) • abnormal constituents –
blood (on surface or toilet paper - hemorrhoids); blood,
(mixed with stool - colitis, dysentery); mucus; pus;
steatorrhoea (stools bulky, yellow, offensive, difficult to flush
away, leaving greasy stain on lavatory pan)
Disturbance of function • urgency • sense of incomplete
emptying • incontinence Piles/haemorrhoids • how long
present? • painful? • bleeding? • prolapsing?
Jaundice • urine dark, pale stools, sclera and skin yellow •
constant, fluctuating or progressive? • itching?
Miscellaneous • sore tongue? coated tongue? swollen
tongue? • bad breath (halitosis)? • dry mouth? Malabsorption
• oedema? • skin lesions? purpura? • bone pain? • anemia?
symptoms of anemia?
 Genitourinary System

Bladder • frequency - during day and/ or night (nocturia) •

flow rate, volume • retention • dribbling •
urgency/strangury/precipitancy • pain (dysuria) • enuresis
(bed wetting)
Urine • color – clear, turbid, blood (hematuria) • smell •
passage of stones, grit • loin pain • site, character, radiation
(e.g. to groin)
Oedema • ankles, dependent oedema • abdomen, ascites •
facial, peri-orbital swelling
 For Males

Specific questions • impotence • urethral discharge –

purulent, mucoid, blood-stained • prostatism – poor urine
stream retention of urine, nocturia • prostatitis – pain at end
of micturition • injuries
 Central Nervous System (CNS)

Handedness(right or left handed)

 Loss of consciousness • sudden – warning; tongue biting;
injuries sustained; passage of urine/ incontinence; duration
after effects; precipitating cause; relief with food (sugar)
Mental state • memory – short and long term • independent
opinion of relative or friend should be sought • hallucinations
• agitation • delusions • intellectual changes
Headache • character • site • duration • associated
symptoms – vomiting • aggravating or relieving symptoms -
time of day, change in posture, straining (e.g. defaecation,
micturition)
Weakness or paralysis of limbs or any muscles • sudden
• gradual • progressive • distribution
Abnormalities of gait • dragging leg, dragging or drop foot,
wearing out toes of shoes? pattern of shoe wear • rolling or
staggering; on side? dominant side?
Numbness or “pins and needles” in limbs or elsewhere
(paraesthesias) • loss of sensation? • smoking, or cooking,
burns of fingers?
Dizziness / giddiness • rotational vertigo? • clumsiness? •
dropping things? • difficulties in movement? Visual
disturbance • seeing double (diplopia)? • dimness of vision? •
‘Zig-zag’ figures (fortification spectra)? • visual field defect?
Tremors, Deafness • lateralized? • high or low pitched
sounds? • history of noise exposure? • tinnitus (ringing in
ears)
Sphincters • incontinence, fecal, urinary • retention of
urine?
 Speech disturbance • duration • onset – sudden, gradual •
nature – dysphasia, dysarthria
 Endocrine System

Hair alterations in hair growth – baldness; hirsutism –

distribution of hair (male pattern etc.) Weight • weight
gain/time • weight lost /time • weight at key ages • appetite
Specific questions • thirst and polyuria (diabetes insipidus)
 changes in skin, voice and bowel habit (e.g. hypothyroidism –
coarse skin, dry skin and hair, weight gain and hoarseness) •
temperature preference • neck swelling • pigmentation •
sweating • visual disturbance (fields) • flushes • growth
abnormality • tremor • libido
 Haemopoetic System

Sore tongue • pernicious anemia

Blood loss • menorrhagia • haemorrhoids; obvious upper or
lower GI bleeding; haematuria
Pallor Bruising Symptoms of anaemia • tiredness •
breathlessness • palpitations • ankle swelling • angina •
intermittent claudication
Occupation Exposure to irritants, drugs, sunlight Rashes •
type • situation • duration • treatment? • painful? • itching
(pruritus)? Pigmentation • distribution?
 Musculoskeletal System

Swelling of joints • one joint or multiple joints, symmetry,

distribution
 Pain • time of day? • effect of exercise? • flitting (from joint
to joint) or fixed?
Stiffness • effect of exercise? • morning stiffness?
Mechanical dysfunction • in terms of normal activity •
standing, walking, activities of daily living (ADL – e.g.
combing hair)
Previous bone or joint injury • recent or distant past?
 5.PAST HISTORY

Illnesses (with dates): ask specifically about childhood

infections, tropical infections, hypertension, diabetes, TB,
jaundice and epilepsy – note, if absent • operations • injuries
• vaccination • insurance examination • obstetric and
menstrual history.
 Past medical history, and allergies

Ask for previous illness, drugs and allergies.

Childhood illnesses
Ask if the patient completed immunization(pediatrics)
Last date of admission
Any history of chronic illnesses like
dm,hypertension,cancer,etc
Ask for serostatus(HIV status) and date of last HIV test.
Developmental milestones(pediatrics)
 Past surgical history

Ask for history of any operations (surgical procedures) and

reasons.
History of blood transfusions; number of times and reason for
transfusion.
Ask for history of any accidents.
 Obstetric and gynecological history

History of pregnancies • Outcome, including abortion

(spontaneous or therapeutic), with dates. Usually written as
Para x+y (Parity - where x is the number of completed and y
the number of failed / incomplete pregnancies).
• miscarriages – gestational age, associations (e.g. fetal
malformation, pre-eclampsia)
Menstruation • age at onset (menarche) • age at cessation
(menopause) • menses – regularity, duration, volume, pain
(dysmenorrhoea)
Intermenstrual discharge • character e.g. purulent, blood
stained • intermenstrual pain (site, character etc.) • date of
last menstrual period • prolapse
Dyspareunia (pain during intercourse) Incontinence • stress
(e.g. on coughing)? • continuous? Contraceptives
 Family History

Birth order, number of children in the family and health of

siblings. health of partner. any similar or serious illness in
parents, grandparents, siblings (family tree).
 longevity of family members: cause of death • in “genetic
disease” construct family tree Very often, valuable
information about the patient’s complaints, family history and
social background can be obtained by interview with
relatives.
This is always essential in pediatric practice, and often
essential in adult medicine, for example, when the patient is
unable to communicate.
 Drug History

any medications, taken in the past and for current illness •

current medications should be listed accurately, with the dose
and timing e.g. Amlodipine 10mg o.d.
Also include “over-the-counter” (OTC) Medication, such as
ibuprofen • ask about and record any adverse drug
reactions/allergies
• ask about recreational drug use.
 Social and Personal History

occupation - whether employed or unemployed • location, type, size of house

(where necessary)- the need to climb stairs, for example, may prevent
patients returning to their own house
• family circumstances, e.g. housing, living with parents, number of
dependents
• hobbies and recreations • tobacco (cigarettes, cigars, pipe) – present
smoker or ex-smoker (record number of years). Calculate “Pack Years” –
packets per day x years
• alcohol - weekly amount, type, past history of alcoholic intake (note
importance of reliable corroboration). Calculate units per week .
• Physical exercise - number of times per week on average • Duration of
exercise on average - intensity: mild/moderate/intense (advice is for
minimum of 5 x 30 minutes of moderate exercise per week)
General examination.
HEENT(HEAD, EAR, NOSE& THROAT),examination of the
system in the presenting complaint and the vital signs.
summary
Short summary of name, age, sex, occupation, Presenting
complaints
Relevant past medical history, and examination findings
impression: the most likely diagnosis basing on history
taking and physical examination( the initial opinion of the
doctor by examining the patient).
Differential diagnosis: a list of possible conditions that
share the same signs and systems after history taking and
physical examination.
This helps to arrive at the correct diagnosis.
Investigations
Diagnosis
Management plan
THE END