ANAMNESIS

don’t write anything that is normal/unrelated

Name

Age

Sex

CHIEF COMPLAINT

Admission date, Emergency/ Programmed.

Main cause of admission, main signs and symptoms.

• where, onset, severity, type of pain

FAMILY HISTORY

Father : age, alive/death, any pathology, under treatment/ no treatment

Mother:

Brother/ Sister :

Son/ Daughter:

PERSONAL HISTORY

Allergies , Vaccines (# COVID doses,) , Surgery (if any, date and treatments, if no papers it's “undocumented”), Recent or past (childhood) pathology (age of diagnosis, treatments), bleeding tendencies, blood group

• Digestive - ask for UC, ulcers, neoplasms, hepatic diseases (Wilson's, hemochromatosis), anemia, transfusions, tattoos, DM

(if female patient)

First menstruation, Last menstruation, Regular/Irregular bleeding, Pregnancies (if any, numbers and description of any problem related to it) , Abortion, hormonal medications

SOCIAL HISTORY

City, Country side/ Center, Garden/Apartment/House, Animals, Alone/Roommates, Job environment, Lifestyle (exercise, diet), Sexual orientation.

Who does the cleaning, shopping, cooking ?

Digestive - hepatotoxins, hepatitis, diet (fiber, intolerances), smoking (→ pancreatic cancer, peptic ulcers), alcohol (→ gastritis, GERD, peptic ulcers, ASH)

RISK FACTORS/ CHRONIC INTOXICATION

Smoking (how long, packs/day, start and end)/ Alcohol (quantity, type, start and end)/ Coffee

(frequency)/ Drugs (start, end)

Smoking index = years smoking/packs per day

• 66

  20-22 is risk for cardiovasc disease

DRUG HISTORY

Mediations (frequency), Treatments

#-#-#, F=tablets

• Digestive - amiodarine → hep, contraceptives → cholestasis, paracetamol → acute liver necrosis

HISTORY OF PRESENT ILLNESS / EPICRISIS

Patient, age, sex, presents to hospital emergency/on appointment.

Current + past pathologies

Onset, Setting of development, Manifestations, Treatment.

Each symptoms: Location, Type, Quantity/Severity, Timing.

What exacerbates it ? What relieves it ?

Intoxications that correlate

Meds if related

Ex :The patie wasnt Andrei Ioan has been admitted at the clinic on appointment the 26/04/21 afternoon presenting with nausea, vomiting, epigastric pain and fatigue. The onset was on the 23/04/21 around lunch time when he started to feel a burning sensation of the stomach and chest discomfort. After a while he started to feel nauseated so he decides to lie on the bed where the symptoms relieve after 30 minutes. In the evening same situation appears after dinner and after he vomited later on he decides to take an appointment with the GP. Manifestation seems to be linked to food ingestion. Epigastric pain, nausea and chest discomfort after meals  so 2/3 times x day, very sharp and burning pain which the patient describes as 8 on a scale up to 10. Bed rest help the patient relieve the symptoms.

GENERAL PHYSICAL EXAMINATION

write everything, if normal put “according to age and gender”

General state : well, relatively well, influenced, severe, critical

Constitution, nutritional state : ( Hypersthenic/ Normosthenic/ Hyposthenic/)

Height

Weight

BMI = weight/(height)^2

• hyposthenic <20

• normosthenic 20-24.9

• overweight 25-30

• obesity I 30-34.9

• obesity II 35-39.9

• morbid/III >40

Consciousness state : conscious, alert, cooperative

Faces : Normal/Hippocratic/Nephritic/ Febrilis/Mitralis/Plethoric (HTN or polycythemia)/Sclerodermic (mummy face, tiny ulcerations, dry, parrot peak nose, wolf teeth)/Basedow or Graves (bulging eyes, retroocular m hypertrophy, exophthalmos)

Endocrine face : Acromegaly (massive supraorbital arcs, big nose + tongue)/ Cushing (moon face, erythematous) / Thyrotoxic/ Myxedema (dry skin)

• Symmetry / Paresis

Lymph nodes: Palpable/Not palpable

• if palpable → inflammatory (rubbery, painful, not adherent) or tumoral (not painful, tough, attached)

• Preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical chain, supraclavicular

  Skin : “normally coloured skin", Color, Hydration (“well hydrated"), “normal skin turgor”, Temperature, Lesions, Mobility, Turgor, Scars

• Translucent + thin → chronic hypoperfusion

Mucosa : Color, Patches/Ulcer, Nodules

• Eyes - conjunctiva pale → anemia, sclera yellow → icterus, watery/dry

• Oral

Connective - Adipose tissue : pear-shaped, apple-shaped, pyknic (short + fat)

Musculo-Skeletal : Hyper/Normo/Hypo Tonic, Hyper/Normo/Hypo Kinetic, Hypo/Normo/Hypertrophic, Gait

Osteo-Articular : “full integrity of bone system”, “no pain in movement”

“good range of motion in all joints. no evidence of swelling or deformity”

• spine percussion → “no pain at spine tap”

Appendages :

• Nails

  

  

• Hair

RESPIRATORY SYSTEM

1. Inspection : Respiratory rate → >20 = tachypnea

• COPD

  • Blue boater → cyanotic lips, clubbing, congestive conjunctiva, hypercapnia, hypoxia

  • Pink puffer → emphysematous thorax, deflated diaphragm, pul HTN, skinny

    

• Cyanosis → tachypneic, blue lips, voluminous breathing, orthopneic position, expressed accessory m, lower limb edema

• Lateral decubitus → laying on one side

  Symmetrical/Asymmetrical thorax

• barrel thorax → ant post diameter is wider, less diaphragmatic mobility, increased intercostal spaces → marker of COPD

• funnel chest (pectus excavatum) → depression in the lower portion of the sternum

• pigeon chest (pectus carinatum) → sternum is displaced anteriorly, increasing the anteroposterior diameter → hypoventilation

• kyphoscoliosis

• 

Movement - “Well maintained diaphragmatic mobility “ (no if using accessory m)

• posterior thorax → thumbs @ 10th rib

• anterior thorax → thumbs @ costal margins

2. Palpation : Tactile fremitus Hyper/Normo/Hypo resonant (normal, increased, decreased, or absent)

   Tactile fremitus - physiologically decereases

   • Absent → pleural effusion

3. Percussion: Hyper/Normo/Hypo resonant with Mobile/Stuck diaphragm.

(locate pathological resonance), ant thorax not necessary

• start at supraclavicular

• seated patient, hugging arms

• not to be done in emphysema

• to count intercostals → 7th intercostal space is lower edge of scapula

Hyperresonance → COPD

Hyporesonant → atelectasis

Auscultation : “normally detectable/present bronchial breathing and vesicular sounds”

FIRST - bronchial breathing → lower neck + subclavicular spaces

• ask patient to breathe thru mouth

• at what point in resp cycle does the sound occur?

• left vs right side

• Transmitted voice sounds → patient says “ee” → “a” sound = pneumonia

• reduced sound → local is pneumothorax, effusion, pneumonia (@ base)

  • global is COPD, asthma

• Wheeze → continuous musical whistling in ant thorax, narrowed airways → asthma + COPD

  • stridor → inspiratory

• Crackles (rales) → discontinuous, from fluid, coarse is infection, fine is fibrosis, physio @ base, LHF

• Ronchi → low-pitched, “snoring”

• Rub → “step in snow”, in both phases, in dry pleuritis (not wet)

• Atelectasis → increased tactile fremitus, percussion dullness, abnormal breath sounds

• if unsure if physio sound → ask patient to cough, if increased sound it’s patho (pneumonia)

CARDIOVASCULAR EXAMINATION

Patient supine w/ upper body raised 30 degrees, or turned to left or leaning forward - examiner on right side

1. Inspection of precordium - scars, v collaterals, chest shape (left asymmetry from congenital RVH, precordium bulge from effusion, barrel from cor pulmonale, parasternal bulge from aortic aneurysm), pulsations (→ SVC/subclavian v obstruction, parasternal is a. dilation), abnormal movements (inward apex excavation in systole from adhesive pericarditis)

   1. Harzer sign - epigastric pulsation from RVH or in thin patients, visible pulsation of apical beat in DCM

2. Palpation - apex beat (normal/strong/diffuse/impalpable), Palpable/ Not palpable cardiac thrills, 5th intercostal space on midclavicular line (lay patient on left if can’t feel it), normal diameter is 1 intercostal space

   • LVH + dilated cardiomyopathies change 6th intercostal space

3. Percussion - Cardiac dullness in Normal/Abnormal range showing a Normal/Abnormal sized heart

4. Auscultation - Rythmic/Arythmic cardiac sounds with/without superimposed pathological sounds or bruits  (locate and describe pathological sounds)

   • diaphragm - 1 + 2nd heart sounds, systolic murmurs

   • bell - 3rd + 4th heart sounds, diastolic murmurs

   • l lat decubitus - for mitral stenosis, S3, S4

   • sitting + forward - for aortic regurgitation

• standing up - mitral valve prolapse

Mitral - 5th interspace, at apex (best for hearing S1)

Tricuspid - 4th interspace, l sternal edge

Pulmonary - 2nd interspace, l sternal edge

Aortic - 2nd interspace, r sternal edge

Erb-Botkin - 3rd interspace, l sternal edge (for aortic insufficiency, pericarditis)

• patent ductus arteriosus - 1+2nd interspaces below l midclavicular area

Feel carotid pulse (occurs w/ S1)

Murmurs: must describe timing, intensity, location of max intensity, radiation, pattern, character, variation w/ position

“medium pitched, grade 3/6, blowing holosystolic murmur, best heard at apex, radiating to left axilla” (mitral reg.)

S3 - “ken-tuck-y”, gallop

S4 - “da-lub dub”, before S1 (late diastole)

Extra hearts sounds:

Pericardial friction rub - scratching, high-pitched, use diaphragm on Erb point, patient forward

Systolic - midsystolic click (av valve prolapse), high pitched, heard medial to apex, patient sitting + forward

• ejection click (semilunar stenosis), high-pitched early in systole, w/ diaphragm at a or p areas

Diastolic - opening snap (mitral stenosis), early in diastole, @ apex at l lat decubitus position

• pericardial knock (constrictive pericarditis), in early diastole

1. Peripheral pulse -

   1. JVP (assesses right heart) - OF IJV, supine, 15° trunk elevation, press on liver if you can’t see it (hepatojugular reflux)

   2. radial (medial to styloid process), temporal (in front of ear), carotid (for pulse character + waveform, supine, 15° trunk elevation, medial to scm), brachial (medial side of fossa), femoral, popliteal (deep), post tibial (post+inf to medial malleolus), dorsalis pedis (lat to exterior hallucis longus, b2 1+2nd metatarsals)

Rate, Rhythm, Symmetry, Quality (pulsus bisferiens in aortic reg, collapsing, celer + altus, parvus + tardus, filiformis)

Radio-radial pulse + radio-femoral pulse if abd/arcus aortae stenosis

Vital signs - BP, HR, RR, temp

ECG

1. Cardiac rhythm - origin, rhythmicity (sinus rhythm)

• P waves + in leads II and aVF, normal is DII + V1

• 1 big square - 0.2s

• ventricular rhythm - R-R intervals

• atrial rhythm - P-R intervals

2. HR: 300, 150, 100, 75, 60, 50

   

3. Axis - are heights of QRS from leads I and aVF + or - ? (physio +) Where do the quadrants overlap?

• normal is 0-90°

  

4. QRS

5. ST segments + T waves

6. PQ + QT intervals

Aortic regurgitation - by asc aortic dissection, RF, IE

• LV v overload → increased LV end-diastolic → increased pul p → dyspnea + pul edema

• Manifestations - widened pulse p (bw systolic + diastolic), water-hammer pulse, apical beat hyperdynamic, Quincke sign, S3, early diastolic murmur, Austin Flint murmur (mid-diastolic)

• Investigations - ecg shows LVH + left axis deviation, pbc and cultures +

Aortic stenosis - by calcification (DM) or RF

• increased LV afterload → LVH → decrease systemic flow → MI

• Manifestations - angina, syncope, HF, powerful apex beat, ejection click, S3+S4, crescendo-decrescendo systolic murmur, radiates to carotids

• Investigations - BNP, ecg shows LVH, AF

Tricuspid stenosis - by RF, IE, lupus

• less flow to RV → RAE, obstructed v return (hepatomegaly, less pul flow, edema)

• Manifestations - edema, fatigue, increased JVP, RVH, ascites, tricuspid opening snap, diastolic murmur

• Investigations - CBC, tall P waves (RAE), AF and atrial flutter (for albin)

Tricuspid regurgitation - by RF, IE, prolapse, diseases causing pul HTN

• RV v overload → RHF

• Manifestations - of RHF (edema, ascites, hepatomegaly), JVD, S3+S4 (increases w/ ins),

• Investigations - no ECG abnormalities, cardiomegaly, dilated RV on echo

Pulmonary stenosis - by congenital diseases

Pulmonary regurgitation

• either by pulmonary valve dilation (pul HTN), by infection or congenital

• Manifestations - dyspnea, angina, edema, palpitations, abd distention, JVD, palpaple S2, S split, Graham steel murmur (early diastolic decrescendo), holosystolic tricuspid regurgitation murmur

• Investigations - ECG shows RVH + E

Mitral stenosis - by RF

• Calcified valve → left atrial p increased → pul v HTN → AF

• Manifestations - LFH (dyspnea, orthopnea), mitral face, apical impulse lat displaced, opening snap

• Investigations - LAE, RVH on ECG

Mitral regurgitation - by RF, myxomatous degeneration

• increased preload → increased stroke v → increased left atrial pressure

• Manifestations → LHF (dyspnea, orthopnea, pul edema), S2 split, holosytolic murmur towards axilla

• Investigations - BNP, LVH + LAE in ECG, AF

ABDOMINAL EXAMINATION

Inspection : In supine position the abdomen Is/Is not in xypho-pubian plane

Participating/Not participating in respiratory movements.

Teguments, collateral circulations, stretch marks

Normal hernia free points With/Without protruding masses.

Auscultation : Normal/Abnormal , Present/Absent peristaltic movement.

Palpation : feet lying or bent

1. Superficial palpation : on each quadrant

Abdomen is Elastic/Tender in…(which one)… quadrants With/Without specific tenderness or pain.

2. Deep palpation : along each quadrant, Elastic/Tender abdomen, Murphy sign Positive/Negative, use 2 hands

Palpate liver - patient takes deep breath, upwards movements w/ fingers, feel surface of liver then edges, Inferior margin of the liver Is/Is not palpable

• croash/Murphy maneuver → sticking fingers under ribs after patient takes deep breath

Spleen is/Is not palpable. - palpate from right iliac fossa to other side, patient taking deep breaths

• palpable when enlarged, portal htn, you can feel inf pole

Kidneys - one hand pressing on top, the other under to touch kidneys

• palpable in liver enlargement, PKD

Percussion : supraumbilical then to lateral borders, liver in interspaces, splenic border, suprapubic

Hyper/Normo/Hypo resonant percussion Alternating/ Not alternating tympanic and dullness sounds.

Fluid wave test for ascites is Negatve/Positive

Shifting dullness - turn on one side and wait, percuss from lat to medial, transmitted on palm thru impulse of movement by liquid → ‘wave sign’ of ascites

Liver - percuss for prehepatic diameter is 12cm, (lowest part you hear dullness) → inf margin, work up

• from right iliac fossa → thoracic cage

Spleen - from right iliac fossa to axillary line, bw 7-9th interspaces

Kidney - in acute urinary retention, tympanic sounds physiological

Giordano maneuver bilaterally Positive/Negative

Duodenal ulcer - pain occurs after eating (after an hour)

Dysphagia : difficulty swallowing, check for tumours, achalasia, peptic ulcers, if oropharyngeal it's infections or Zenker's, if esophageal it's tumors or peptic strictures

Odynophagia : swallowing feels painful, caused by chemical irritants

Heartburn : caused by peptic ulcers, GERD

Dyspepsia : indigestion, gastric is nausea and vomiting, intestinal is defecation disorders

Tenesmus : urge to go toilet but can't go, check for rectal cancer if with blood

Nausea and vomiting: in acute cholecystitis, pancreatitis, gastroenteritis, gastroparesis

• If morning - alcoholics and pregnant

• If after eating - peptic ulcers, psychiatric

• If 4h after meal - gastroparesis

• Continuous - depression

• Irregular - major depression

Green vomit - bile (small bowel obstruction)

Undigested food - achalasia

Partially digested - gastroparesis, gastric outlet obstruction

Hematemesis - upper GI bleed (above angle treitz)

Pruritis - pregnant, cancer, cirrhosis

Gastroparesis : early satiety, post prandial bloating, abd discomfort

Diverticuli - dilations, cause extreme bleeding

Peptic ulcers - episodic pain after meals

Biliary pain - severe, right upper/epigastric, after fatty foods

Pancreatic pain - epigastric radiating to back, relieved by sitting up/leaning

Small bowel obstruction - periumbilical

Colonic pain - like small bowel but relieved by defecation/flatus

Bowel ischemia - right upper/central, exacerbated by eating

Renal colic - lumbar (costovertebral angles), tender to touch

Bladder pain - suprapubic, diffuse, severe

Prostatic pain - dull, in lower abdomen or rectum

Ureteral pain - variable, exacerbated after urination

Topographical divisions

• Murphy sign - acute cholecystitis, 9th interspace

• Bar from left to right - acute pancreatitis

• Appendicitis - McBurney point → 1/3 iliac spine - umbilicus

- Lanz point → 1/3 of the way between the two anterosuperior iliac spines

- Gerota clock - position appendix

- Iacobovici triangle - linea alba, Lanz, McBurney

- Iupsoas manoeuver - raise legs and press on appendix

• Courvesier sign - pancreatic head tumour

• Virchow/Troisier node - gastric tumour

• Acute pancreatitis - Turner sign - flank bruises, Cullen sign - periumbilic bruises

Immobile patient - peritonitis

Patient on all 4s - pancreatitis

Obesity - w/ cholelithiasis (female, fatty, 40)

Peripheral edema - nephrotic syndrome, cirrhosis, malabsorption

Limbs :

• Leukonychia, koilonychia - hypoalbuminemia

• Clubbing- cirrhosis, IBD, celiac

• Blue lunale nails, Keyser Fleischer rings - Wilson's

• Palmar erythema - liver

• Dupuytrens contracture

• Axilla - adenopathies from gastric cancer (Virchows nodes)

• Circumoral pigmentation - peutz jager

• Tongue - iron/B12 deficiency swollen, leukoplakia in alcohol, candidiasis in iron deficiency

• Acanthosis nigricans in axilla - DM

Findings:

• Abdomen is firm, smooth, elastic, painless, palpation was not tender, no pathological resistances