CMED 400 CLINICAL METHODS D.

K NERU

EGERTON UNIVERSITY

COLLEGE OF OPEN AND DISTANT LEARNING

THE E-CAMPUS

CMED 222: CLINICAL METHODS

BY

MR. DAVID K. NJERU

Email; njerud93@yahoo.com

Cell; +254728803290

Edited March 2020

1
 CMED 400 CLINICAL METHODS D.K NERU

Introduction
Clinical methods course is mandatory for all who interact with patients with
the aim of making a diagnosis and managing the patient. The systemic
approach to a patient client is not easy. A clinician must convince the
patient client that he she is worth being trusted with the information and
examination required for the patient. In order to gain patients confidence, it
is important to create a strong rapport with the patient client. Creation of
rapport does not only make the patient open up but also it is therapeutic.
The systemic approach in the process of diagnosis making therefore forms
core component of medical practice. Medical history should be systematic
and should be followed by meticulous physical examination
Course content
1. Topic one: introduction of clinical methods
2. Topic two: creation of rapport
3. Topic three: elements of history taking
4. Topic four: environment for physical examination
5. Topic five: general examination
6. Topic six: vital signs
7. Topic seven: systemic examination
8. Topic eight: summarizing the case
9. Topic nine: ordering investigations
10. Topic ten: Writing prescription
Course objectives

1. To initiate and develop the teaching of basic practical clinical

2. skills to students in a safe and structured environment by reinforcing the
existing bedside and clinical learning
3. To support the transition of the student’s clinical skills learning
4. from the simulated training environment to the clinical area
5. To provide a facility for the structured assessment of clinical
6. skills and other competencies including continuing accreditation
7. To ensure that the student receives uniform teaching opportunities
8. whilst on clinical attachment to a local district hospital by working with
local trainers and sharing educational resources
9. To integrate the learning of practical clinical skills with the
10. skills of communication and team working – enabling the patient’s
experience of the clinical encounter to remain central to a student’s
clinical skill development
11. To promote clinical teacher development and enable research into
12. Medical education and assessment methods.

COURSE OUTLINES

1. Demonstrate medical professionalism while dealing with patients/ clients

2. Demonstrate cordial clinician – patient relationship
2
 CMED 400 CLINICAL METHODS D.K NERU

3. Record health data obtained through history taking

4. Perform comprehensive physical examination
5. Exude positive attitude while dealing with colleagues and patients/ clients
6. Demonstrate knowledge on requesting relevant investigations
7. Diagnose and mange patients as per the training of clinical medicine
program
1. INTRODUCTION
Clinical method is a term used to describe a properly organized approach
to the patient and to his or her disease. A good clinician should not only aim
at reaching a diagnosis but should be able to help the patient and family
manage the problems caused by the disease and where possible offer
treatment cure or prevention. Clinical methods are acquired by a
combination of study and experience, and there is always something new to
learn
1.1 History development
The current edition was published in May, 2017 and edited by Elsevier.
Since his first publication, clinical methods has been modified and improved
to the current practice which is global. They have also been translated into
several other languages. Hutchison’s had several petitions among the
notable; “ from putting knowledge before wisdom, science before art, and
cleverness before common sense; from treating patients as cases and from
making the cure of disease more grievous than the endurance of the same,
Good Lord deliver us.”
1.2 Practice of Clinical Methods
1. Medicine is a fast changing subject, is nowadays dominated by
investigations instead of clinical skills in making the clinical diagnosis.
There is no doubt that with fast development of science and
availability of new techniques for investigations, the diagnosis can be
made accurately but at exuberant cost. In the present era, the
practice of medicine is changing; clinical skills have been pushed to
back seat. I must say that clinical skills make up the clinical sense of
the students/physicians thus cut short the demand of unnecessary
investigations.
2. The human mind is a computer, can see and interpret the clinical
signs on the bedside and can give provisional diagnosis
instantaneously. A good bedside examination can narrow down the
differential diagnosis and provide you a concise approach for
investigations and thus curtail the cost of investigations. The
developing countries cannot afford such costly investigations just for
pretty ailment/diseases, for example CT scan for just headache.
3. History taking is detective work. Preconceived ideas, snap judgments,
and hasty conclusions have no place in this process. The diagnosis
must be established by inductive reasoning. The interviewer must first
determine the facts and then search for essential clues, realizing that
the patient may conceal the most important symptom—for example,
the passage of blood by rectum—in the hope (born of fear) that if it is
not specifically inquired about or if nothing is found to account for it in
the physical examination, it cannot be very serious

3
 CMED 400 CLINICAL METHODS D.K NERU

2. TOPIC TWO: CREATION OF RAPPORT

2.1 The cornerstone of a good relationship between clinician and patient is
trust. In primary health care, this relationship patients expect a high
standard of behavior and care when they seek medical help.
For a clinician to obtain important information from the patient he must
establish a good rapport. This can be done by the following;
 Clear introduction of the clinician to the patient. (E.g. I am a
Clinical Medicine student e.t.c.)
 A warm handshake to the patient
 Looking empathetic
 Listening to the patient keenly
 Maintaining the eye contact
 Allow the patient to talk freely without interruption
 Guiding the patient by seeking classification
2.2 Autonomy -The fundamental principle underlying medical ethics is
autonomy: The patient has the right to decide his or her own medical
destiny. This gives rise to the concept of seeking the patient’s consent
for medical interventions, for research and for teaching.
2.3 Consent -The patient’s consent should be sought for any treatment,
however minor, even when that consent might appear implicit as, for
example, by attendance at an emergency unit with injury. Sometimes
assessment of a minor symptom discloses a separate, more serious
issue There are four requirements of the clinician discussing an
intervention with a patient:
2.3.1 The procedure itself must be described, including the technique and
its implications, and the intended benefit of doing it.
2.3.2 Information about the risks and complications must be given, which
usually means all the risks, as well as some information about the
consequences of the complication
2.3.3 Associated risks (e.g. from anaesthesia or from other drugs that may
be necessary) should be described.
2.3.4 Alternative medical or surgical investigations or treatments should be
discussed, so that the reasons for the specific advice given are clear.
The fact that all aspects of the medical consultation are confidential
forms the foundation for the consultation, as it allows the patient
freedom of expression in the knowledge that disclosures made within
the confines of the consulting room will not be made available to
others eg. HIV Testing for HIV requires the consent of the patient or
individual. It is usual to counsel the individual about the
consequences of a positive result before testing, as there are
implications for lifestyle, future health and even employment hinging
on the result of the test. The patient expectations includes the
following;
3. TOPIC THREE: HISTORY TAKING
3.1 Taking history is a misnomer term. The patient tells a story. It is the
clinician who constructs a medical history from entrenched narratives,
parables and family myths. The story maybe very disorganized but the
medical history has to be systematic. The process of gathering
information about a patient often begins by reading any referral
4
 CMED 400 CLINICAL METHODS D.K NERU

documentations and with the immediate introduction of doctor and

patient. The history is concerned with extraction of symptoms from the
patient which are subjective. while signs are elicited during physical
examination is concerned with signs and which are objective and are
demonstrated by the examining clinician
3.2 The aim of the history taking is to obtain and document a complete
picture of the patient’s present condition. In a well taken history a
clinician can make a diagnosis in 85% of the cases. A concrete
diagnosis may not be essential in every patient but a working diagnosis
or differential diagnosis is necessary. . No patient should leave a
medical consultation feeling that nothing can be done to help them,
even when the disease is incurable
3.3 Importance of history taking
3.3.1 Patient may label himself wrongly
3.3.2 The prognosis is much easier to access when an accurate diagnosis is
made.
3.3.3 Information concerning investigations treatment and prognosis can
be sought from medical literature.
3.3.4 Management is more effective when a diagnosis is made.
3.3.5 The interview history taking may have a therapeutic role by itself.
4. Topic 4:Elements of history taking
Elements of History Taking
The medical history consists of the following elements.
1. Patient’s identification (patient’s particulars)
2. Chief complaints
3. History of the presenting illness
4. Review of the systems
5. Menstrual history{for females}
6. Obstetric history{for females}
7. Past Medical & Surgical History
8. Personal, Social, and Economic History
9. Family history
a. Patient Identification (Patient’s Particulars)
Importance of identifying a patient
a) Communication with the patient
b) Continuity of care - While giving out the patient drugs
c) For statistical purposes
d) For medical legal purpose
e) Research and education
f) Historical purpose
Patient’s identification includes the following information:
i. Name -The name of the patient should be clearly written down.
ii. Postal and physical address e.g. Estate, road, and building and
postal box number cellphone number. This is important in case of
follow up or contact tracing eg in case of notifiable contagious
diseases
iii. Age in years or months-
 Some conditions are related to ages,

5
CMED 400 CLINICAL METHODS D.K NERU

 To decide whether information provided can be relied on e.g.

patients under 14years have to be accompanied by
parents/relatives/guardians,
 To decide Which ward to admit the patient
iv. Sex whether a male or a female- some conditions are related to
gender, to decide where to admit the patient
v. Date of admission- to monitor the progress of the patient, for
records purposes, drugs dosages.
vi. Ward number- for records and tracing purposes.
vii. In patient number-for records and tracing purposes
viii. Next of kin- to be contacted in case of operation, death e.t.c
ix. Religion- some religions don’t believe in medicines, or vaccines.
b. Chief Complaints (C/C)
i. This is the main symptom that has made the patient to seek
medical attention. The patient might have been unwell at home for
a long time but there reaches a time when the patient decides to
seek medical attention. Ask the patient question a regarding the
main reason for which he/she is seeking medical consultation.
ii. Most of the patients have mainly one or two complaints which are
recorded in chronological order easily but sometimes because of
nervousness, anxiety, apprehension and fear, they may exaggerate
the symptoms to gain sympathy. Make a list of complaints that are
recorded in an order in which the most troubling complaint
becomes the presenting complaint.
c. HISTORY OF PRESENTING COMPLAINT(S) (HPI)
i. This is the most important part of medical history. It elaborates on
the chief complaints. Allow the patient to tell you the story of his
problem from the beginning up to the end without interruption.
Interaction should only be made if the patient talks irrelevant
things. The clinician converts the story to medical history by writing
it in a chronological order.
ii. History of presenting illness should begin by ascertaining when the
patient was last perfectly well and should continue with the details
of the presenting symptoms e.g. the patient has been well until 4
days ago when…instead of writing the actual date gives more
important information. All the events from the time the first
symptoms started up to the time you are taking history should be
recorded in their order of occurrence.
iii. The information should be sought by probing the patient rather
than by asking leading questions. The symptom should then be
expounded one at a time e.g. if the patient complaints of pain the
following information should be sought.
iv. When there is a history of trauma for example, the details must be
established as precisely as possible. What was the patient’s position
when the accident occurred? Was consciousness lost? Post
Traumatic Amnesia (PTA) (inability to remember events just
preceding the accident) always indicates some degree of cerebral
damage. If a patient can remember every detail of an accident, has
not lost consciousness, and has no evidence of external injury to
6
 CMED 400 CLINICAL METHODS D.K NERU

the head, brain damage can be excluded. In the case of gunshot

wounds and stab wounds, knowing the nature of the weapon, its
size and shape, the probable trajectory, and the position of the
patient when hit may be very helpful in evaluating the nature of the
resultant injury
v. Any form of first aid or treatment given to the patient should be
documented. This should be followed by what was done at the
hospital when the patient first reported including the investigations
that were done and treatment at the casualty.
vi. The specific management given in the ward should be well
documented. This should be followed by review the system (s)
affected Important negative symptoms should be documented.
Lastly the clinical state the patient the time of clerking and what
the patient is awaiting
d. ERABOATION OF SYMPTOMS
 Pain
The International Association for the Study of Pain proposed the following
definition (1979): ‘Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or described in terms of
damage’
 Vomiting
Type of vomiting can be -Projectile – vomitus comes out forcefully and
patient throw it at a distant Or Non – projectile is effortless and vomitus
falls at the feel of the patient
i) Color – yellowish green is an indication of presence of bile
ii) Content – feculent vomitus contains fecal matter or It may also
contain food preciously taken that has not been digested yet.
iii) Timing – after meals may indicate gastrine indications e.g. gastric
ulcers.
- morning
- any time
iv) Nausea – preceding vomiting
- No nausea e.g. ICP – increased intra cranial – pressure
 Diarrhea
Is frequent passage of watery stools (more than 300mls) in a day. A change
in bowel habits is a common complaint that is often of no significance.
However, when a person who has always had regular evacuations notices a
distinct change, particularly toward intermittent alternations of constipation
and diarrhea; colon cancer must be suspected.
 Cough
1. Enquire if the patient is coughing
2. If so, is the cough productive (wet) or dry
3. If productive does it contain blood (Haemoptysis) means the coughing up
of blood in the sputum?
4. If productive ask about the color, amount whether blood stained etc
5. Associated chest pain/ difficulties in breathing.
6. How long has the cough been there
7. Is the cough worse at night or during the day

7
 CMED 400 CLINICAL METHODS D.K NERU

 Hematemesis
Vomiting out of blood is called hematemesis. Bleeding from any orifice
demands the most critical analysis and can never be dismissed as due to
some immediately obvious cause. The most common error is to assume that
bleeding from the rectum is attributable to hemorrhoids.
 Hematochezia passage of fresh blood through the anus
Maleana passage of dark hard stools through the anus
e. REVIEW OF THE SYSTEMS (SYSTEMIC REVIEW)
Under review of Systems questions may uncover certain problems that the
patient has overlooked, particularly in areas unrelated to present illness.
Remember that: “major health events should be moved to the present
illness or past history in your write-up.
In order to make certain that important details of the past history will not be
overlooked, the system review must be formalized and thorough. By always
reviewing the systems in the same way, the experienced clinician never
omits significant details. Many skilled clinicians find it easy to review the
past history by inquiring about each system as they perform the physical
examination on that part of the body. NB. The system affected should be
reviewed in the HPI
1. RESPIRATION SYSTEM
a) Cough – enquire if the pain has coughed. If present ask whether it
is productive or dry. If it is productive ask about the
- amount – copious or much
- color – yellow e.g. in bronchitis
- content – blood stained (hemoptysis) e.g. in TB
b) Chest pain – if present ask all the factors pertaining to pain.
c) Difficulties in breathing – enquire about the timing and the position.
d) Wheezing – this is blowing musical sounds from the lungs due to
partial obstruction.
2. CARDIO VASCULAR SYSTEM
a) Ask about pain over the proecordum (area covering the heart)
b) Palpitations (awareness of heart beat at rest)
c) Swelling of the lower limbs.
d) Shortness of breath -When does it occur, i.e. at rest or on
exertion?
e) Orthopnoea- shortness of breath while lying flat
f) Easy fatigability - Fatigue or tiredness is a common complaint of
patients with heart failure, coronary artery disease, persistent
cardiac arrhythmia, hypertension and cyanotic heart disease. It is
due to poor cerebral perfusion and oxygenation
3. GASTRO INTESTINAL TRACK
a) Dysphagia - means difficulty in swallowing.
 Is there any difficulty in swallowing?
 Is there any sticking of the food during swallowing?
 Is it worse with solids or liquids?
 • Is swallowing painful?
b) Odynophagia means painful swallowing usually results from
esophagitis due to gastrointestinal reflux disease or candidiasis
e.tc.
8
 CMED 400 CLINICAL METHODS D.K NERU

c) Globus hystericus means a sensation of lump in the throat without

any organic cause, occurs in anxious or hysterical patients Ask the
patient if he has pain on swallowing
d) Abdominal pain ( describe the pain in the same manner)
e) Vomiting- ask whether it is projectile or non projectile, the amount
and the content
f) Any diarrhea. If present how many monition in a day, content e.g.
blood, mucous, food previously taken etc.
g) Anorexia (Loss of appetite)- If present try and differentiate
between actual lack of appetite or fear to feed e.g. in gastric ulcer.
h) Constipation – passage or hard stools.
 Enquire how often the patient opens the bowel
 Absolute constipation if he doesn’t at all
 Flatus -Passage of gas through the anus – flatulence.
4. GENITAL URINARY SYSTEM.
a) Dysuria-Enquire about pain during micturition.
b) Colour of urine
 Is it clear or turbid when passed?
c) Haematuria -Is there any blood in urine?
 If so, at what part of micturition is it present?
d) Frequency- Is there any increased frequency or burning
micturition?
 Do you get up at night? How often?
 Is frequency associated with increased thirst (polyuria and
polydipsia)?
 Is there any retention of urine with overflow incontinence?
 Do you ever leak any urine? or wet yourself involuntarily?
e) Any discharge from the urethra if present asks about colour,
smell and amount.
f) Frequency of micturation .g. it is increased in diabetes mellitus &
decreased in renal failure
g) Pneumaturia-It refers to passing air bubbles in the urine.
 It is caused by a colo-vesicle fistula due to diverticular
abscess
 malignant disease
h) Urgency - Feeling like passing urine – urgency as it happens in
prostatitis
i) Ulcers on the genitalia
j) Puffiness of face and oedema- Morning puffiness of face,
periorbital oedema and pitting pedal oedema are characteristic
features of renal diseases (nephritic and nephrotic syndrome) and
renal failure due to any cause
8. Menstrual history for women: -
a) Menarche – The onset of the menstruation normal age 14 years
(average 12 – 16 year).
b) Duration of circle – normal 28 days on average this may be affected
by climate, psychological stress, diet or diseases and drugs, 21- 35
range.

9
 CMED 400 CLINICAL METHODS D.K NERU

c) Amenorrhea is failure of menarche by age of the 16 irrespective of the

presence or absence of secondary sexual characteristics or the
absence of menstruation for 6 months in a woman with previous
normal menses.
d) Duration of flow – normal is 3-8 days average
 content of blood
 Clots
 Fresh.
e) Menopause – ceasation of menstrual flow
 Normal is about 50 yrs.
f) Dysmenorrhea – pain during menstruation
 This is usually common in young women before age 25 years.
 Spasmodic dysmenorrhea-It may be due to spasms
 congestive dysmenorrhea – heavy flow
g) Any discharge form the vagina and the colour, smell
9. Obstetric history:
a) Last menstrual period (LMP)
b) Number of children
 0+ 0 means a lady has never given birth and is not pregnant.
c) Miscarriages – discharge of products of conception after 28 days of
pregnancy
d) Abortions – expulsion of products of conception before 28 days.
e) Methods of deliveries – assisted – vacuum
 SVD – Spoteneous vertex delivery
 C/S – ceaserean section.
 Assisted deliveries- vacuum extraction
10. Musculoskeletal system
a) Arthralgia- pain in a joint or joints disease
 History of trauma
 Does the pain move from one joint to another (fleeting joint
pains of rheumatic fever and gonococcal arthritis).
 What is the distribution of joint pain, i.e. whether involves
small (rheumatoid arthritis) or large joints (osteoarthritis)?
 Is there any family history of gout or other rheumatic
disorders? • Has the patient been exposed to rubella? • Is there
any gait/posture abnormality?
b) Swelling around the joints-Is the joint visibly swollen
c) Difficulties in movements
d) Oblivious deformities
e) Myalgia-It is a muscular pain in the absence of muscle weakness
11. Central nervous system
a) Involuntary movements-Neurological disorders especially involving the
basal ganglia and extrapyramidal system manifest with certain
involuntary or unintended movements
b) headaches
c) Fainting /Syncope attacks - refers to loss of postural tone, inability to
maintain erect posture followed by unconsciousness. It is a symptom
of decreased cerebral perfusion- It occurs commonly in standing
position due to postural drop in BP
10
 CMED 400 CLINICAL METHODS D.K NERU

d) blurring of the vision

e) hearing problems
f) Seizure is defined as an episode of neurological dysfunction
 Convulsions are seizures accompanied by motor manifestations,
i.e. limb jerking, incontinence of urine or faeces or both etc.
 Seizures need not be always convulsive, it may be manifested
by other changes in the neurological functions, i.e. sensory,
cognitive, emotional events etc
f. PAST MEDICAL & SURGICAL HISTORY
Importance of past history
a) Certain illnesses in the past may cause complications related to the
present illness, for example, childhood infectious illness may cause
pulmonary complications in adulthood.
b) Similarly adult illness in the past may have important bearing on
the symptoms of present illness
 Obstetric/ gynaecological past history (menstrual history,
birth control, and sexual function) carry significance in a
female presenting with gynaecological complaints.
c) Any history of previous admissions which should include an account
of all previous major illness or operations.
d) If the patient had operation in the past, note the date and place
where it was done.
e) History of blood transfusion and drug allergy is very important if
the patient has traveled outside his normal residence it should be
note.
f) List the medicines being taken by the patient. Try to ascertain—
tactfully—which of their medicines they are in fact not taking, and
the reasons for this. This is vital information, which is elicited
sympathetically and not by accusations
g) It is also important to know if the patient has been exposed to X –
Rays and how many times.
h) Food allergies
i) Patient may give ready-made diagnosis of his/her illness that
occurred in the past. In that eventuality, it must be verified by
asking what actually happened during that illness so as to conclude
whether diagnosis is likely or less likely. At times, it may be
necessary to communicate with doctors or hospitals that have
treated the patient in the past
g. PERSONAL, SOCIAL AND ECONOMIC HISTORY
This history give a picture of the patient back ground, occupation, home
environment, personality and social behaviour.
a) Personal history; The number of siblings ;The position in the family;
Marital status- In men, particularly if unmarried, remember the
possibility of homosexuality. Both in males and females,
homosexuality is frequently associated with personal and social
stresses
b) Occupation;Exact nature of work/ occupation;You can ask him about
former occupations, if any; One should also ask about the attitude

11
 CMED 400 CLINICAL METHODS D.K NERU

towards work, employer and fellow-workers;Try to find out financial

worries.
c) Habits
 Smoking- if so, note type, number of sticks, number of years
 Alcohol drinking- type of alcohol, content, addiction
 Abuse of drugs -contribute to the disease, hence, inquires into
these habits is often necessary.
 Patient may be defensive and may deny or minimize their
substance use, in such a situation questioning should be tactful,
firm and persistent to get the full information either from him or
from a relative.
d) Home environment
 Type of house-
- Temporary -Ask about his house whether it is made of
mud (kuccha house)
- Semi-permanent-bricks and cemented (pucca)
- Permanent – made of stone, iron sheets and cemented
floor.
Source of water -Ask the patient the source of domestic water and
storage e.g. rain water, river, dam, tap, e.t.c and whether it I boiled
before use. Refuse disposal- Note how the it disposes off the refuse
e.g. dumping, burning, and collected by local council. Excreta
disposal- Does the patient use toilet and what type / e.g. pit Food
regularly taken -What type of food is used regularly.
j) FAMILY HISTORY
The purpose of taking a family history is to obtain audience of similar
disease in other members of the family in order to help in the patient
diagnosis and also to be able to give advice to other members of the family.
a) Some diseases are clearly inherited.
 Ask whether the parents are alive and if they are well. Inquire
about chronic disease in the family e.g. tuberculosis, diabetes,
hypertension.
b) Presence of any chronic illness in the family e.g. TB, diabetes,
TOIC FOUR: ENVIRONMENT FOR A GOOD CLINICAL EXAMINATION
 The clinician should be well groomed
 The privacy of the patient should be ensured
The room should be well ventilated
 The room should be warm
 It should have good light avoid coloured bulbs.
 The minimum furniture in the examination should be
o Furniture and equipments
 Two simple chairs
 a simple drug cupboard
 examination equipments
 a coach & a table
o If necessary a chaperone should be present when a male clinician is
examining a female patient..
 Note facial appearance, built, complexion, and state of clothing.

12
 CMED 400 CLINICAL METHODS D.K NERU

 Observe and define any abnormality of mental state, consciousness,

gait, posture and movement.
 Measure the height and weight
 A good bedside examination can narrow down the differential diagnosis
and provide you a concise approach for investigations and thus curtail the
cost of investigations. The developing countries cannot afford such costly
investigations just for pretty ailment/diseases, for example CT scan for
just headache Our patients are poor, cannot afford so much on
investigations, require cheap diagnosis which can be provided by
accurate and better interpretation of clinical signs and symptoms.
 Many patients are apprehensive about being examined. The environment
is unfamiliar; they may feel exposed and are likely to have anxieties
about the findings. Be open about your status as a medical student or
junior doctor. Reassure the patient that the extra length of time you take
to complete your examination compared to someone more senior is
because you are less experienced and that it does not necessarily imply
the findings are worrying
 The elective physical examination should be done in an orderly and
detailed fashion. One should acquire the habit of performing a complete
examination in exactly the same sequence, so that no step is omitted.
When the routine must be modified, as in an emergency, the examiner
recalls without conscious effort what must be done to complete the
examination later. The regular performance of complete examinations
has the added advantage of familiarizing the beginner with what is
normal so that what is abnormal can be more readily recognized.
 Generation of clinicians has warned that clinical examination is dying. The
problem is progressive disuse atrophy. The new technology of imaging
and other investigations is to blame for this. It is easier to arrive at a
diagnosis by use of these investigations than in clinical examination.
More over, the medical school curricular has become so overloaded that
practical skills such as history taking and clinical examination are being
crowded out. It is however, important to note that many health facilities
cannot afford these investigations.
 The art of clinical examination has to be learnt. It does not come
naturally. Looking comes first, an of course continues while we feel and
while we are examining movements. It requires stern self discipline to
refrain from e.g. touching a lump, the movement you see it. Feeling
should be methodical, encompassing first the skin then the particular
structure then the joint capsule and then bones. For most patients, start
the examination on the right of the bed/couch with the patient semi
recumbent (approximately 45°
 Physical examination should be done in a systematic order. The following
is the order in which it should be carried out.
TOPIC FIVE: GENERAL EXAMINATION
Traditionally one starts off the examination by performing a so time you
may appreciate just how useful the clues gleaned from the general
examination are in defining the nature and extent of illness in your patient.
You must therefore train yourself rigorously to relate the findings on general
examination to the findings in the systems, and, during the course of the
13
 CMED 400 CLINICAL METHODS D.K NERU

examination, to refer back constantly to these “general” findings to confirm

and enlarge upon your suspicions. Explain on the patient on what you want
to do. Expose the area you want to be examined adequately
a) General condition – note whether the patient is
 Mildly in looking
 Moderately in looking
 Severe in looking
 In severe pain or discomfort
 You will note this from the facial expression of the patient.
b) Nutrition status- this is the build of the patient
 Well nourished
 Malnourished (Bmi–Body mass index 18- 25. weight (kg)
Height m2
 Obesity – patient with Bmi of make than 25.
 Wasted – patient with Bmi of less than 18.
 Cachexic – massive wasting whose features include prominence
of the bones.
 Parameters of assessment are:
- Dietary history
- Clinical assessment
- Anthropometry
- Biochemical assessment
c) Consciousness – it is important to note whether the patient is
 Fully conscious- responds to pain & verbal stimuli
 Semi – conscious – responds to painful stimuli but not verbal
& stimuli
 Unconscious – does not respond to pain or verbal stimuli.
d) Decubitus – this is the position of the patient in bed.
 Note whether the patient is;
- propped up
- lying flat
- Restless.
e) Pallor (anemia) – this is reduced haemoglobin in level of blood for a
particular age and sex. The term anemia is applied when the
haemoglobin level is known and is lower than normal.
 Normal males 13 – 18 gms%
 Females 12 -17 gms%
 Children 14-20 gms%
 Areas for checking pallor
f) Jaundice – this is yellow colouring of the sclera, skin an mucous
membranes caused by excess circulating bilirubin in blood. It manifest
when the levels are three times the normal.
 It is classified as: -
- tincture (mild)
- moderate
- Severe (leads to Kernicterus) brain damage.
g) Cyanosis – it is the blue appearance of the skin and mucors
membrane due to high levels of circulating deoxygenated blood. It can
be divided into central and peripheral cyanosis.
14
 CMED 400 CLINICAL METHODS D.K NERU

 Central cyanosis occurs when deoxygenated blood mixes with

oxygenated blood in the great vessels of the heart or the lungs.
 Peripheral cyanosis occurs when local circulation is impaired
and there is great extraction of oxygen from the haemoglobin
by the tissues.
 Sites for checking cyanosis
- sclera
- Frenium of the tongue
- Tip of the nose
- Ear lobes
- Hail beds
h) Finger clubbing – definition: - it is the obliteration of the angle
between the nail bed and the skin (lovibonds angle) due to chronic
peripheral hypoxia. It is an important sign of disease of the heart,
lungs and alimentary canal. The pathology behind finger clubbing is
not very clear but there is a neurocirculatory component because the
constant feature of clubbing in an increase in the vascularity of the
distal fingers and consequently an increased sponginess of the nail
bed. The lovibonds angle is obliterated. It tends to affect the index
finger first and hence should be examined first.
i) Dehydration – It is loss of fluid in the body. It is 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 true index
of dehydration as it is lost in old age and due to loss of collagen in the
skin
j) Dyspnoea (respiratory distress)
This is a sign of a respiratory disorder it presents with
a) flaring of nasal alae
b) resetion of the costal & intercostals muscles
c) In chest expansion.
k) Lyphadenopathy
This is enlargement of the peripheral lymph nodes.
Site: - cervical – anterior, posterior; Occipital;sub – mental; submandibular;
clavicular – supra
- Infra auricular – pre – auricular; Post auricular; Auxiliary – anterior;
Inguinal;Popliteal
l) Oedema
Definition: - swelling of the ankle region due to accumulation of body fluids.
It can be pitting or non – pitting (browny)
Kolonychia – this refers to brittle nails with character spoon shape which will
hold a globule of water and which suggests chronic non deficiency.
TOPIC SIX: VITAL SIGNS
There are four vital signs. They are vital because they are indicators of
seriousness of a disease when altered. They include:-
a. Blood Pressure
b. Respiratory
c. Temperature
d. Pulse
15
 CMED 400 CLINICAL METHODS D.K NERU

1. Blood Pressure

Important clinical decision are made on the basis of blood pressure reading
so it is vital that blood pressure techniques are used to ensure accurate
measurement and that the equipment (sphygmomanometer) is in good
working order. Blood pressure varies within 24 hours depending on the
variety.

Procedure for taking blood pressure using sphygmomanometre:-

1. Position the patient comfortably on the coach preferably propped up at
450C.
2. Tie the cuff of the blood pressure machine above 2.5cm above the
cubital fossa.
3. the machine should be at the same
4. Palpate the brachial pulse and then inflate the cuff until the pulse
disappear increase by 30mmHg after the disappearance of the pulse.
5. Place the diaphragm over the cubical fossa and start deflating the cuff.
6. The first heart sound korotkove denotes the systolic blood pressure,
note the diastolic blood pressure; note the reading on the column.
7. Continue deflating the cuff until the sound muffles or disappears this is
the diastolic blood pressure; note the reading on the column.
8. the boll pressure should be recorded as
Systolic
Diastolic
The pressure varies according to the age.
Normal systolic is 100 -140 mmHg
Diastolic is 60 – 90

The difference between diastolic and systolic is called Pulse pressure. The
normal pulse pressure is 30-60mmHg.
Hypotension is blood pressure below the normal
Hypertension
Pulsus paradoxicus – reduction in systolic pressure by more than 10mmHg
on inspiration e.g. constrictive pericarditis severe asthma
The blood pressure in children is taken using a small cuff. It can however,
be calculated,
Thus; 88 + 2a, where, a, stands or age in yrs
55 + a
Calculation of height 6x+ 77 (cm) where x= age
PULSE
Def: - it is a wave transmitted through an artery after the contraction of left
ventricle; while taking the pulse from a patient; the following should be
noted;
1. Rate – the normal range is by convention 60- 90 beats/min. if regular,
the pulse rate may be counted over either 10 or I5S and multiplied by
either 6 or 4. But irregular pulse 30s is recommended.

16
 CMED 400 CLINICAL METHODS D.K NERU

Bradycardia is pulse rate below 60 BPM e.g. in Hypothyroidism;

Hypothermia; intra cranial pressure. Drugs – beta blockers, digoxin, heart
block.
Tachycardia is pulse rate above 90bpm and may be observed in
 exercise
 fever
 hyperthyroidism
2. Rhythm the rhythm may be;
 Regular
 Regularly irregular
 Irregularly irregular
Pulse deficit is the difference between the radial pulse and pulse
determined at cardiac apex.
3. Character – the character of the pulse is best assessed by palpation of
the carotid arteries it can be;
o Normal
o Slow rising upstroke e.g. aortic stenosis
o Collapsing e.g. aortic regulation
4. Volume
 Normal
 Small volume e.g heart failure shocks.
5. Condition of the vessel wall – it can be soft – in young or in the old.
6. Areas where pulse can be taken:
 Radial pulse; Carotid pulse; Temporal; Femoral pulse; Anterior
tibial; Posterior tibial

2. TEMPERATURE
This is measured in degree Celsius ( 0C) using mercury thermometer. It can
be taken in the following areas;
a. Armpit (axula)
b. Under the tongue (oral) in conscious
c. Groin in children
d. Rectum in children
e. Virginal
 The normal temperature is 36.5o C – 37.2 o C
 Subnormal 35 – 36.5 oC
 Hypothermia < 35 oC
 Pyrexia (fever) 37.2 – 41oC
 Hyper pyrexia > 41oC
3. RESPIRATION
The following should be noted: -
a. Respiratory rate – in an adult the rate is 16 -18/ min and is best
counted when the patient is at rest and without the knowledge of the
patient. The rate is increased in pneumonia, anxiety, and acidosis and
in pneumatic pain.
b. Rhythm – the rhythm can be normal which is regular with occasional
deep breaths chyn stroke respiration has a very characteristics pattern
in which success breaths become deeper until a maximum is attained
when there is a period of apnoea and the cycle is repeated.
17
 CMED 400 CLINICAL METHODS D.K NERU

c. Abnormal which is irregular

d. Character - Cheyne-Strokes breathing is the name given to a
disturbance of respiratory rhythm in which there is cyclical deepening
and quickening of respiration, followed by diminishing respiratory
effort and rate, sometimes associated with a short period of complete
apnoea; Kausmal breathing
TOPIC SEVEN: SYSTEMIC EXAMINATION
Systematic examination should be done in an orderly manner. The
respiratory system should be examined first, followed by cardio vascular,
per abdomen, musculoskeletal system and finally central nervous system.
The usual approach is to inspect (look) palpate (touch) percussion and
auseuttation in that order. The approach in MSS and CNS is a bit different.
a. RESPIRATORY SYSTEM
The systematic examination should be approached in a systematic manner
where inspection (looking) is done first then palpation (touch) followed by
percussion (tapping) and finally auscultation- Listening with a stethoscope.
INSPECTION
The front of the chest should be inspected first with the patient propped at
450C and then the back.
The following should be noted;
 Dyspnea -It is defined as consciousness of breathing which normally does
not occur except during severe exertion, emotional stress or during
anxious events. It can be cardiac or respiratory origin. The following
should be examined
- Flaring of alae nasal; Recession of costal and subcostal muscles
 Shape of the chest
 Chest movement-In absence of spinal deformity, diminished movement
on one side indicates disease on that side.
 Scars-Note whether they are;
 Operational
 Therapeutical
 cosmetic marks.
 Oblivious mass over chest wall should be noted
 Gynaecomastia. Enlargement of the breast due to proliferation of breast
tissue in males is called gynaecomastia. It can be physiological i.e. mild
breast enlargement in the male may occur during puberty and may
persist for several years
 Stridor It is loud sound produced by partial obstruction of a major airway
(e.g. laryngeal oedema, tumour, an inhaled foreign body
PALPATION
The following should be palpated for: -
i. Tenderness
This is pain on touch. You will note by the facial expression of the patient.
Note the site.
ii. Position Of The Trachea - Feel for deviation of the trachea
♦ Place the palm of the hand either flat on the patient’s upper sternum the
middle finger into the suprasternal notch to rest on the trachea. By slipping
the finger off the trachea to left and right, gauge whether it lies more to one
side or the other.
18
 CMED 400 CLINICAL METHODS D.K NERU

The normal trachea in fact often lies slightly to the midline of the chest
The trachea may be pulled to one side by collapsed lung or fibrosis. It may
be pushed to the opposite side by pleural effusion or pneumothorax. It may
be disposed by tumors of the neck.
iii. Vocal Fremitus
Vocal fremitus is detected with the hand on the chest wall. It should,
therefore, perhaps be regarded as part of palpation, but it is usually carried
out after auscultation. This is increased over consolidated lung and
diminished when air, fluid or thickened pleura separates the lung from the
chest wall or when a major bronchus is occluded.
iv. Chest Expansion
Grab the chest with both of your hands and let the two thumbs touch each
other. Look at the gap the thumb makes as the chest expand normal is 3 -5
cm.
v. Mass
Note if there is any mass. If present note the site, the shape, the
consistency, the attachment to underlying and overlying structures, local
temp and tenderness.
PERCUSSION
The technique of percussion was probably developed as a way of
ascertaining how much fluid remained in barrels of wine or other liquids. The
percussion note is determined by the thickness of the chest wall by the
aeration of the underlying lung and by any structure intervening between
the lung and the chest wall it can have the following tones
TECHNIQUE
 The clavicles are percussed directly and then interspaces of the Ribs.
Always compare both sides of the chest
 The middle finger of the left hand is placed on the part to be
percussed and pressed firmly against it, with slight hyperextension of
the distal interphalangeal joint. The back of this joint is then struck
with the tip of the middle finger of the right hand (vice versa if you
are left-handed). The movement should be at the wrist rather than at
the elbow.
 The two most common mistakes made by the beginner are, first,
failing to ensure that the finger of the left hand is applied flatly and
firmly to the chest wall and, second, striking the percussion blow from
the elbow rather than from the wrist
i) Resonant over normal lung Resonance. The normal degree of resonance
varies between individuals, and in different parts of the chest in the same
individual-Reduction of resonance (i.e. the percussion note is said to be dull)
occurs in two important circumstances:
ii) Dullness over solid lung (consolidation) or thickening of pleura1 when
the underlying lung is more solid than usual, usually because of
consolidation or collapse.
2 When the pleural cavity contains fluid, i.e. a pleural effusion is present
iii Stony dullness –note detected by presence of a hard mass
iii) Hyper – resonant over hyper inflated lung such a bronchial.
Emphysema or pneumothorax.
AUSCULTATION
19
 CMED 400 CLINICAL METHODS D.K NERU

 Listen to the chest with the diaphragm, not the bell, of the
stethoscope.
 Chest sounds are relatively high pitched, and therefore the diaphragm
is more sensitive than the bell. Ask the patient to take deep breaths
in and out through the mouth.
 The chest should be auscultated for the breath sounds and the added
sounds. The flow of air through the trachea always generates some
noise. As air passes through the many division of the bronchial tree,
the sound is modified by normal lung tissue which acts as a filter.
 The normal heart sounds are called vesicular breathing. When the
trachea noise is modified due to consolidation the sounds are passed
unchanged and are heard over the chest wall as bronchial breathing.
i. Vocal response is a sound made by a consolidated lung when a patient
repeats some wards e.g. nine-nine the chest is then Auscultation for
added sounds.
ii. The normal breath sounds. Breath sounds have intensity and quality.
The intensity (or loudness) of the sounds may be normal, reduced or
increased. The quality of normal breath sounds is described as vesicular.
iii. Added sounds. Added sounds are abnormal sounds that arise in the
lung itself or in the pleura
 Crepitation – these are non musicle explosive sounds caused by
the rapid movements of air which occurs when an airway opens
with a pop.
 Rhonchi, explosive continuous sounds often described as bubbling
or clicking. When the large airways are full of sputum, a coarse
rattling sound may be heard even without the stethoscope.
However, crackles are not usually produced by moistness in the
lungs Plural rub is a sound likened to creating leather which is
thought to be generated by inflamed plural surfaces rubbing
against each other during respiration
 Pleural rub -the pleural rub is characteristic of pleural
inflammation and usually occurs in association with pleurisy pain.
It has a creaking or rubbing character (said to sound like a foot
crunching through fresh-fallen snow) and, in some instances, can
be felt with the palpating hand as well as being audible with the
stethoscope.
 Vocal resonance and vocal fremitus is the resonance within the
chest of sounds made by the voice. Vocal resonance is the
detection of vibrations transmitted to the chest from the vocal
cords as the patient repeats a phrase, usually the words ‘ninety
nine’ or one- one -one
b. CARDIOVASCULAR SYSTEM
The patient should be examine while seated or propped up in 45 0.
INSPECTION
vi. Chest wall deformities such as pectus excavatum should be noted, as
these may compress the heart and displace the apex
vii. the patient should be inspected for any abnormal pulsation at the neck
viii. any dilate blood vessels over the chest which could be due to

20
 CMED 400 CLINICAL METHODS D.K NERU

The apex beat (position) this is the outer most and lowest pulsation palpable
and is normally in the 5th intercostals space on the mid clavicle line.
It can be displaced in;
PALPATION
1. Apex beat Palpate to confirm the position of the Apex beat
 The apex beat is defined as the lowest and most lateral point at
which the cardiac impulse can be palpated
 Locate the apical pulsation with the palm of your hand, and then
pin it down with the tips of a few fingers. If you cannot feel the
apex, try with the patient lying on their left side. It will often now
be palpable. If still impalpable, do not forget to consider a
dextrocardia. And percuss to the right of the sternum to detect.
2. Heave which I caused by left ventricular dilation caused or aortic or
mitral incompetence.
3. Cardiac thrill (this is an abnormal vibration or a palpable murmur.)
PERCUSSION
Percussion is done to determine the boarders of the heart. It is increased in
pericardial effusion or a large aneurysm of the Aorta.
AUSCULTATION
Positioning the patient
 Auscultate with the patient in all the following positions:
 Lying at 45° - listen briefly over the aortic, pulmonary, tricuspid and
mitral areas with the diaphragm
 Sitting forward - now listen carefully over the aortic, pulmonary and
tricuspid areas with the diaphragm, in both deep inspiration and in
expiration.
 Lying on the left side- listen with the bell at the mitral area
To become skilled in auscultation of the heart one requires a great deal of
practice. The diaphragm and bell of the stethoscope permit appreciation of
high- and low-pitched auscultatory events, respectively. The apex, lower left
sternal edge, upper left sternal edge and upper right sternal edge should be
auscultated in turn. These locations correspond respectively to the mitral,
tricuspid, pulmonary and aortic areas, and loosely identify sites at which
sounds and murmurs arising from the four valves are best heard
The order of Auscultation should be the following:
i. Mitral area – at the cardiac apex.
ii. Aortic – to the right of the sternum in the 2nd intercostals space.
iii. Tricuspid – to the right of the lower and of the sternum.
iv. Pulmonary – to the left o the sternum in the 2nd intercostals space.
The following should be ausculated for:
a) Normal heart sounds
First sound (S1) Describe the first sound. Listen at the apex and at the
lower end of the sternum the left side.
b) Heart murmurs
 These are caused by turbulent flow within the heart and great
vessels. Occasionally the turbulence is caused by increased flow
through a normal valve – usually aortic or pulmonary –
producing an ‘innocent’ murmur

21
 CMED 400 CLINICAL METHODS D.K NERU

 They are usually due to abnormal communications within the

heart. They have a blowing sound murmur can be: murmurs can
be soft or loud.
 Heart murmurs are defined by four characteristics: loudness,
quality, location and timing
 The loudness of a murmur reflects the degree of turbulence.
This relates to the volume and velocity of flow and not the
severity of the cardiac lesion
 The quality of a murmur relates to its frequency and is best
described as low, medium or high-pitched.
 The location of a murmur on the chest wall depends on its site
of origin and has led to the description of four valve areas;
mitral, tricuspid, aortic, and pulmonary
 The timing can be;
l) systolic
m)diastolic
c. PER ABDOMINAL EXAMINTLION
The human gastrointestinal (GI) tract is a complex system of serially
connected organs approximately 8 m in length, extending from the mouth to
the anus, The patient should be lying supine with arms loosely at the sides,
the head and neck supported by up to two pillows, sufficient for comfort A
sagging mattress makes examination difficult, particularly palpation. Make
sure there is a good light, that the room is warm and that the hands are
warm. Stand on the patient’s right side and expose the abdomen by turning
down all the bed clothes except the upper sheet. The clothing should then
be drawn up to just above the xiphisternum and the sheet folded down to
the level of the symphysis pubis
Examination of per abdomen includes;
• Gastrointestinal system
• Urinary system
• Hepatobiliary system
i. Let the patient lie flat in supine position and symmetrically on bed.
The patients hands should at the sides with the head resting on a
pillow
ii. The examination is referred to as per abdomen and not GIT because it
also includes ballottement for the kidneys.
iii. The general approach is inspection, palpation, percussion and
auscultation. However there are some circumstances when inspection
can be followed by auscultation if by palpating and percussing the
clinician thinks that the bowel sounds will be altered and are major
finding.
iv. Expose the patient adequately up to mid-thigh
v. Drape the patient with a towel/ sheet

22
 CMED 400 CLINICAL METHODS D.K NERU

The abdomen can be divided into nine imaginary regions to aid in

description.

A B C

D E F

G H J

A – Right hypochondrium – liver & gall bladder

B - Epigastrium – stomach & Duodenum
C – Left hypochondrium – spleen
D – Right limbar region – right kidney
E – Umbilical region – small intestines
F – Left lumbar region – left kidney
G – Right iliac fossa – Appendix, ovaries
H – Hypogastric region urinary bladder
J – Left iliac fossa – Rectum and left ovaries
INSPECTION
The examiner should stand at the foot of the bed
The abdomen is inspected for the following
a) Shape - Shape Is the abdomen of normal contour and fullness, or
distended? Is it scaphoid (sunken)?
b) Distension of the abdomen. It could be due to 5fs.
 Fat eg truncal obesity due to any cause, fatty hernia
 Fluid -ascites, ovarian cyst, distended bladder
 Fetus in pregnancy
 Feaces e.g. acute intestinal obstruction, a dynamic ileus or
paralytic ileus
 Flatus
 tumors
c) The umbilicus normally the umbilicus is slightly retracted and inverted.
If everted check if it’s a hernia by cough reflex
d) Abdominal movement – thoraco abdominal normally there is a gentle
rise in the abdominal wall during inspiration and a fall during
expiration; the movement should be free and equal on both sides. In
generalized peritonitis, this movement is absent
-patients with renal stones move rapidly as they writhe with pain unable to
find a comfortable position
e) Visible pulsation of the abdominal aorta may be noticed in the
epigastrium and is a frequent finding in nervous, thin patients. It must
be distinguished from an aneurysm of the abdominal aorta,
 Obstruction at the pylorus. Visible peristalsis may occur where
there is obstruction at the pylorus
 Obstruction in the distal small bowel. Peristalsis may be seen
where there is intestinal obstruction in the distal small bowel

23
 CMED 400 CLINICAL METHODS D.K NERU

 As a normal finding in very thin, elderly patients with lax

abdominal muscles or large, widenecked incisional herniae seen
through an abdominal scar.
f) Symmetry of the abdomen
g) marks
h) distended veins
There may be visible normally during pregnancy. In portal hypertension may
be distended vein around the umbilicus (capulmedusac). Obstructed inferior
vena cava causes distension over the abdomen due to saphenous vein blood
being diverted to the auxiliary vein.
PALPATION
 Palpation forms the most important part of the abdominal
examination. Tell the patient to relax as best he can and to breathe
quietly, and assure him that you will be as gentle as possible.
 Enquire about the site of any pain and come to this region last. The
best palpation technique involves moulding the relaxed right hand to
the abdominal wall, not to hold it rigid. The best movement is gentle
but with firm pressure, with the fingers held almost straight but with
slight flexion at the metacarpophalangeal joints and certainly avoiding
sudden poking with the fingertips Before palpation, enquire from the
patient if there is any region in pain. If there is, you palpate it last.
Look at the facial expression of the patient as you palpate. The
following scheme is suggested, which may need to be varied according
to the site of any pain:
 Start in the left lower hypochondria of the abdomen, palpating lightly,
and repeat for each region.
 Repeat using slightly deeper palpation examining each of the nine
areas of the abdomen.
 Feel for the left kidney.
 Feel for the spleen.
 Feel for the right kidney.
 Feel for the liver.
 Feel for the urinary bladder.
 Feel for the aorta and para-aortic glands and common femoral
vessels.
 If a swelling is palpable, spend time eliciting its features.
 Palpate both groins.
 Examine the external genitalia
a) Light touch-the first palpation is light touch for
i. Tenderness –
ii. Rebound tenderness
iii. mass
 Mass abdomen refers to intra-abdominal masses in relation to various
viscera in the abdomen. Mass abdomen may produce fullness of
abdomen or visible swelling, dragging sensation in abdomen, pain
abdomen or may just be asymptomatic i.e. patient is not aware of it.
Malignant masses or tumours produce decreased/ loss of appetite or
weight loss
 note the region where the tenderness is
24
 CMED 400 CLINICAL METHODS D.K NERU

 Site – Feeling the swelling while the patient lifts his head and
shoulders off the pillow to tense the anterior abdominal wall will
differentiate between a mass in the abdominal wall and within the
abdominal cavity exact site
 Shape – oval, round e.t.c
 Surface – rough, smooth, nodular
 Size – in cms.
 Constituency – soft, firm, hard
 Attachment to the underlying structure- Swellings arising in the
liver, spleen, kidneys, gallbladder and distal stomach all show
downward movement during inspiration, due to the normal
downward diaphragmatic movement, and such structures cannot
be moved with the examining hand.
iv. Rigidity or guarding is due to reflex contraction of the abdominal wall,
muscles to protect an area of inflammation. If there is rigidity note
whether there is rebound tenderness. Common cause is acute peritonitis
PALPATION FOR ORGANS
1. Palpation for the liver
Start the palpation from the right iliac fossa upwards. The liver feels like a
wedge
2. Palpation for the kidneys
Kidneys are usually palpated by ballottement
3. Palpation for fluid in the abdomen
1. Shifting dullness-Lie the patient on one side, and percuss their belly
from flank to flank. Percuss with the percussed fingers held
longitudinally along the abdomen, not transversely. Mark with a
light pen mark, the transition from dull to resonant on both sides.
Now lie them on the other side and repeat. Note the extent if any
the line of demarcation between resonance (the gas filled bowel
and dullness has shifted both gas and fluid in the lowermost flank
and in the uppermost flank
2. Succussion splash
3. Fluid thrill-Slap one flank with the palms of the fingers while the
flats of the fingers of the other hand are held against the opposite
flank. If a thrill is felt, but is not unambiguously due to fluid, then
the patient or an assistant may be asked to place the edge of a
hand along the midline of the abdomen, to damp down any thrill
passing through the abdominal wall. A positive is a shock wave
appreciated by the other hand
4. Palpation for gall bladder-(Murphy’s sign)
b) Deep palpation The deep palpation is done to determine
enlargement of the abdominal organs the following organ should be
palpated for:
ii. The spleen: the spleen usually enlarges medially towards the right
iliac fossa. Palpation should therefore start from the right iliac fossa
towards the left hypochondrium. Gauge the size of the spleen by
percussion.
♦ Percuss from the right iliac fossa upwards towards the let upper quadrant

25
 CMED 400 CLINICAL METHODS D.K NERU

Continue percussing across the costal margin on the lateral chest wall so
called Traub’s triangle. If dullness is encountered in the left upper quadrant
or even lower, splenomegaly is likely to be present, since this area is
normally resonant as a result of gas in the stomach. necessary to
differentiate a spleen from an enlarged left lobe of the liver.
PERCUSSION
Remember to rub your hands together to generate warmth whenever you
touch the patient. Press your left hand firmly against the abdominal wall
such that your middle finger is resting on the skin. Strike the distal
interphalangeal joint of the left finger 2-3 times with the tipoff your right
middle finger using floppy wrist action
Percussion is used to;
i. Tympanic ( drum like) sound produced by percussing over air
filled structures
ii. Dull sounds that occur when a solid structure lies beneath the
region being examined
1. Percussion for the liver
- Determine the lower and upper margins of the liver by percussion.
- ♦ Percuss from the right iliac fossa upwards towards the right costal
margin in the mid clavicular line. Note the onset of liver dullness but do
not stop percussing.
- ♦ Continue percussing upwards above the costal margin till you notice the
disappearance for liver dullness.
♦ Note the following three observations:
• The extent of liver dullness below the right costal margin
• The position of the superior edge of the liver in terms of intercostal space
The total span of the liver.
♦ Measure the liver span, from top edge of dullness to bottom edge, using a
tape measure
To help determine the size of the liver. Start just below the right breast in a
line with the mid clavicular.This area will be resonance
Move your finger down until when you hear dullness. Continue downwards
until the sound changes again. At this point you will have reached the
inferior margin of the liver. The area of dullness is called liver span and can
be 6-12 cm
- To determine whether palpate tumours are superficial of deep.
v. Shifting dullness is used to detect the pressure of ascites. The fluid will
cover in the dependent parts of the peritoneal cavity. If the patient is
lying supine the dullness will be at the flanks. If the turns onto his side
then the fluid will again become dependent leaving the upper flank
resonant. i.e. the dullness has shifted)
vi. . If fluid thrill when the generated by tapping firmly on one flank and
detected by feeling the thrill with the other hand place on the opposite
flank. Shifting dullness-
Percussion can be helpful in determining the cause of distension particularly
in differentiating air from fluid.
- Succussion splash- this is done to confirm free fluid in the abdomen. It
may be elicited over a normally full stomach but if very obvious suggests

26
 CMED 400 CLINICAL METHODS D.K NERU

pyloric outflow obstruction. Grab the abdomen with both hands and
shake vigorously. You will hear turbulence in presence of fluid
- Shifting dullness-with the patient lying in supine position, begin
percussion from the level of the umbilicus and move outwards.in
presence of fluid you will reach a point of dullness. Mark this point on
both right and left side of the abdomen and the let the patient role on the
lateral side. Allow for some seconds before you continue with percussion.
The site where dullness was heard will shift and you continue with
tympanic note
AUSCULTATION
Where there is any reason to suspect ileus or obstruction, listen to the
abdomen. Comment on: increased, reduced or absent bowel sounds, and
the presence of the tinkling bowel sounds of ileus
 There is no defined order of auscultation. However it is important to be
systematic starting from one point so that the whole abdomen is
auscultated.
 Bowel sounds-Listen in the nine areas of the abdomen and note the
internal of the bowel sounds (borbogymi) and their pitch or the complete
absence of sounds. Normal bowel sounds is 2-5 per minute. The
stethoscope should be placed on one site on the abdominal wall (just to
the right of the umbilicus is best) and kept there until
 Bowel sounds are sounds are heard increased in intestinal obstruction
 They are absent in peritonitis
 Post operatively for the first 72 hours
RECTAL EXAMINATION
This is performed for the following reasons:
• Where a pelvic problem is suspected, e.g. prostatic enlargement,
prostatitis, Rectal carcinoma
 to obtain a stool sample especially for malena stools or presence of
occult blood
 as a screening procedure for suspected occult carcinoma in the elderly
Procedure
Explain the procedure to the patient and ask their permission. Lie them on
their left side with their knees drawn up as high as possible.
♦ Wearing a lubricated plastic glove, lay your index finger flat on the
perineum and then slide it through the anus. Asking the patient to breathe
in and out deeply helps them to relax. Pause a second and encourage the
patient that it will not be painful.
♦ Now introduce your finger as far as possible and feel anteriorly and
posteriorly, left and right. Note the prostate or cervix anteriorly, in men or
women respectively. Do not confuse this with a mass. Comment on any
other masses, and any specific area of tenderness.
♦ Collect some stool on the finger and remove it. Test it for the presence of
occult blood. if appropriate. Under certain conditions, vaginal examination is
indicated (e.g. ascites, or disseminated carcinoma which might arise from a
pelvic tumour.) Internal examination is then very much part of the medical
examination; it should not be considered something that only gynaecologists
do

27
 CMED 400 CLINICAL METHODS D.K NERU

d. LOCOMOTOR SYSTEM
 The muscular skeletal system is composed of the bone, muscles,
ligaments, tendons, and other connective tissues.it is the mechanism
by which the body performs all the mechanical functions
 While examining muscular skeletal system it is important to keep
functionality in mind.it is important to start proximally as one goes
down. Use the opposite side for comparison. Concentrate at one point
at a time. The ideal examination of the locomotors system should start
when the patient walks in the examination room. Unlike the other
system, the method of examination should include:
a) inspection
b) palpation
c) movement
d) measurements
INSPECTION
Look for any alterations in shape or outline and measure any shortening. In
Paget’s disease (osteitis deformans), bowing of the long bones, particularly
the tibia and femur, is associated with bony enlargement and, usually,
increased local temperature
a) posture or position of the limbs
b) symmetry of the limbs
c) inspect the area for discoloration ( ecchymosis,) redness,
d) Soft tissue Swelling – this could be due to trauma, inflation or growth
or deformity,
e) wasting of muscles.
f) Bony enlargement,
g) Inspect for involuntary muscle movements
h) The back for loss of normal lordosis, scoliosis, kyphosis,
PALPATION
Observe the patients eyes while palpating. The most important indicator of
presence of tenderness. Palpation should be one to elicit:
a) Areas of enlargement and the inconsistency- note if its due to bones or
soft tissues and its boundaries
b) Local temperatures-use the dorsum of the hand from proximal to distal
Ttenderness On palpation, bone tenderness occurs in local lesions when
there is destruction, elevation or irritation of the periosteum Injury is the
commonest cause.
c) Crepitus of joints e.g. in osteo- arthritis or fracture
d) Healing of fracture (callous).
MOVEMENTS
There are two types of movements
a) Active movements- let the patient move by him/herself through an
entire range of movements
b) Passive- the clinician moves a part of patients limb if the patient is
unable to move
c) For straight leg raising test ask the patient to lie with the spine on
a bed to relax completely. With the knee fully extended ask the
patient to slowly lift the limb by flexing the hip. This produces
stretch of the sciatic nerve.
28
 CMED 400 CLINICAL METHODS D.K NERU

NB. If this produces pain in the hip or low back with radiation in the sciatic
area, the test is considered positive for nerve root irritation.
The angle of elevation of the leg from the bed to the point where the pain is
produced should be noted and indicated in degrees
d) At the ankle joint; dorsiflexion being carried out by anterior tibialis
muscle and toe extensors situated anteriorly and the plantar flexion
being carried out by the gastrocnemius, the posterior tibial muscle
and the toe flexors situated posteriorly. The strong Achilles tendon
inserts on the heel posteriorly.
Note any restriction in joint movements whether passive or active they
could be due to contractures, subluxations, abnormal angulations
Note if the joint is stable.
MEASUMENTS
Measurement of the limbs is done to ascertain discrepancy in length and
also confirm swelling by measuring the circumferences
Measure the length of each limb from the anterior superior iliac spine to the
medial malleolus (true shortening). Measure the distance from the umbilicus
to the medial maletus of each leg.
e. EXAMINATION OF CENTRAL NERVOUS SYSTEM
 The approach which follows is intended as an introductory screening
examination
 In the diagnosis of neurological disease, it is the history that is
paramount, so it is even more important for this to be comprehensive
than the examination. History taking has not changed significantly,
but clinical neurological examination continues to evolve.
 The neurological examination is one of the most unique exercises in all
clinical problem. Neurological examination is done to localize a lesion
in central nervous system.
 The examination of the central nervous system like the locomotor
system differs from the other systems’ method of examination.
Because of its lengthy examination taken a suggested minimal
neurological examination for non-neurological patients would be:
assessments of the binocular visual fields, the eye movements, the
biceps, triceps, knee and ankle reflexes, the plantar reflexes and
fundoscopy. Systemic assessment of the unconsciousness patient is an
important part of neurological examination.
 An application of Glasgow coma scale not only provides a grading of
coma by numerical scale but allows serial comparisons to be made for
prognostic information particularly in traumatic coma
The format of full CNS examination should be as follows:
a) Examination of higher center or cerebella function
b) The crania nerves
c) The sensory function
d) The motor function
e) Reflexes
f) Signs of meningeal irritation.
THE HIGHER CENTERS (MENTAL EXAMINATION)
 What we outline here is a screening examination which will allow us to
detect the more obvious deviations from normality; in many cases,
29
 CMED 400 CLINICAL METHODS D.K NERU

such a diagnosis will be sufficient for our purposes; in others, more

definitive analysis as outlined in a subsequent chapter will be
appropriate
 In a fully oriented and cooperative patient, the mental examination
should follow a physical examination. The mental examination should
cover the following areas:
i. General appearance – examine if the patient is well kempt and the
state of clothing.
ii. Behaviour of the patient – note any abnormalities in the manner of
response to question and the mood of the patient.
iii. Consciousness – there are three levels of consciousness
 Fully conscious – responds to pain & verbal stimuli
 Semiconscious – respond to painful stimuli
 Unconscious – does not respond to painful stimuli
Concentration – note if the patient concentrates when you talk to him
i. Delusions – this is a false believes which the patient persist in spite of
demonstration of its falseness.
ii. Emotional status – not whether the patient is calm, anxious,
depressed e.t.c.
iii. Memory – there are three stages involved in remembering
information;
iv. Orientation – test of orientation in time, place and person.
v. Hallucination – the commonest hallucination affects the auditory and
usually senses. If they are present, the patient should be asked when
they occur.
vi. Speech – you will have listened to the content of speech while taking
the history. Note any difficulties in explanation (dysphasia) or
pronunciation (dysarthria) ask the patient to repeat some words like;
o “Baby hippopotamus”
o “British constitution”
o “Artillery”
Dysphasia is impairment in understanding or expressing language.
Syphoned I abnormality of producing sound from the larynx e.g. in
laryngitis. Dyslexia is a condition where a patient cannot recognize word.
Dysgraphia is impairment of communication in writing rather than speech.
CRANIAL NERVES
There are 12 cranial nerves which occur in the following order
 Olfactory
 Optic
 Occulomotor
 Trochlear
 Trigeminal
 Abducens
 Facial
 Vestibular – cochlear (auditory)
 Glossopharyngeal
 Vagus
 Accessory

30
 CMED 400 CLINICAL METHODS D.K NERU

 Hypoglossal
OLFACTORY
This is the first cranial nerve and it is concerned with the sense of smell.
Loss of smell is called anosmia. The commonest cause of anosmia is local
condition e.g. common cold, however, meningioma of the olfactory grooves
can lead to anosmia.
Test: - tell the patient to close the eyes and introduce familiar substance
close to the nose and ask the patient to identify them, failure to do so mean
the olfactory nerve is affected. Familiar substance eg coffee, peel, or vinegar
OPTIC NERVE
The second cranial nerve is concerned with three things i.e.
Visual acuity – use of Snellen’s chart and ask the patient to identify
different figures. If a patient wears glasses it should be tested with or
without.
Color vision – patient is done using Ishihara plates -ask the patient to
identify colours which are familiar to him/her.
Visual fields – examiner and patient sits 1m a part facing each other. The
patient and examiner look at each other nose, the examiner introduce an
object at equidistant starting at the periphery and moves it slowly towards
the midline. Ask the patient to say when he sees the object. Repeat this in
all the four quadrants. This is repeated with the patients and examiners
corresponding eyes closed.
Fundoscopy – fundoscopy should be assessed on both eyes
The pupils
Examination of the pupils and their responses to light and accommodation
provides information not only about specific neurological syndromes which
affect the pupils, such as Adie’s syndrome, but also information about the
integrity of the anterior visual pathways (particularly the optic nerves), the
brainstem and the efferent parasympathetic and sympathetic pathways to
the pupillary sphincter and dilator muscles, respectively.
OCCULOMOTOR, TROCHLEAR & ABDUCENS NERVES
These nerves supply the extra ocular muscles and are examined together.
 Occulomotor supplies;
 Inferior oblique
 Medial rectus
 External rectus
 Internal rectus
 Trochlear supplus – superior oblique
 Abducens supplies – lateral rectus
All the rest are supplied by Occulomotor nerve.
PARALYSIS OF THE NERVES
1. Abducens – leads to inability of the eye outwards movement and
diplopia.
2. Trochlear – impained power of downwards movement; an attempt to
look downwards makes the eye ball to rotate inwards by inferior
rectus.
3. Occulomotor – ptosis the eye is dispose downward and outwards pupils
is diverted & fixed loss of power accommodation.

31
 CMED 400 CLINICAL METHODS D.K NERU

Test: - ocular movements are tested by asking the patient to gaze with both
eyes at the examiner finger. The examiner holds the patients head still with
the other hand. The patient is asked to follow the finger with his eyes. The
pupil is examined for size and shape.
THE TRIGEMINAL NERVE
The trigeminal nerve has two branches; sensory and motor.
The sensory branch has three branches to the face.
Ophthalmic – supplies conjunctiva, upper eyelid lacrimal tip of the nose,
upper forehead.
Maxillary – supply the cheek, front, temporal, lower eyelid ,upper teeth.
Mandibular – lower part of the face and the salivary glands.
Motor – supplies the muscles of mastication.
 Masseter
 Temporal
To test the motor supply tell the patient to clenche the teeth and palpate
the muscles or tell the patient to open the mouth under resistance.
Corneal reflex is also as a result of the trigeminal nerve. Do this by lightly
touching the cornea with a cotton wool. This should cause the patient to
blink
Test sensory: -The test for sensory function.
The following parameter can be used
 Pain
 Light touch
 Temperature
Touch different part of the face with the pts eyes closed and ask him to
touch after you.
Motor: inspect the muscles of mastication for atrophy and then palpate the
temporalis muscles and the masseter for tension. If there is unilateral
affection, the mouth will be pulled to one side when the mouth I opened.
Jaw jerk – tap lower jaw with mouth open.
SEVENTH CRANIAL NERVE
It supplies the frontalis muscles of facial expression weakness of one side
leads to bells palsy (lower motor neuron lesson)
Test:
i) Ask the patient to whistle.
ii) Let the patient puff the cheeks.
iii) Tell him to close the eye and try to open them.
iv) Ask him to show the teeth
v) Tell the patient to frown
vi) Inspect for symmetry of the face.
AUDITORY NERVE / VSTIBULAR COCCLEAR NERVE
This is concerned with hearing and balancing.
Test for hearing
First confirm hearing by introducing a ticking watch close to the ear one at a
time. If hearing is impaired, the following tests are done:
i) Rinne test – place a vibrating tuning folk at 256R/M over the mastold
process and then In front of the auditory meatus. Ask the patient to say
which one he hears well.

32
 CMED 400 CLINICAL METHODS D.K NERU

ii) Test – the vibrating tuning folk is held on the forehead and the patient
asked if t sound is heard in the midline or one ear.
These two tests should be combined with examination of the external
auditory meatus and the tempanic membrane.
Air conduction is usually better than bone conduction.
VESTIBULAR NERVE
The abnormalities of the nerve are associated with vertigo and ataxia.
Romberg’s sign- the patient is asked to stand with the feel together and
then close the eyes.
He fails on the direction which ha a lesion.
GLOSSOPHARYNGEAL NERVE
The ninths cranial nerve is sensory to the palate and posterior 1/3 of the
tongue and the mucous membrane of the pharynx.
Test sensation: - place familiar substances at the posterior 1/3 of the
tongue and ask the patient to identify them. Tickle back of the pharynx and
note a reflex contraction (gap reflex).
Gag reflex
♦ This is appropriate in certain circumstances only; e.g. the elderly patient
with pneumonia who may have aspirated. Open the mo wall of the
oropharynx should move upwards and outwards if the ninth nerve is intact.
Elicit a gag reflex by touching the back of the throat gently with an orange
stick
VAGUS NERVE
Vagus nerve is the most extensive it is motor for the soft palate, pharynx
and larynx.
It is also sensory and motor for respiratory passage.
Test: - the uvular should be examined by the patient to say ‘aah; check that
it lies centrally and does not deviate
(1) ask the patient to swallow saliva.
(2) Ask the patient to produce some word e.g. Egg – eng, Rub – runb.
ACCESSORY NERVE
The 11th cranial nerve supplies the trapezus and the stermastoid muscle ask
the patient to shrug the shoulder and try to resist them. Ask him to turn the
face and try to resist.
HYPOGLOSSAL
Hypoglossal is motor to tongue, ask the patient to protrude the tongue as
far as possible.
Examine for any deviation or atrophy.
SENSORY FUNCTION
Take a good history of any sensory symptoms to build up an idea on how
the sensory function is disturbance is distributed. Use sensory testing to
confirm or refute this distribution pattern. the pattern is confirmed, compare
with the common sensory syndromes to decide on the anatomical site of the
lesion.
In the routine screening of a patient without sensory symptoms, it is
inappropriate to be faultlessly thorough. Test sensation with a sharp object
only (i.e. pain sensation) and do not examine other modalities unless there
is a pointer to such a problem. Use a stick rather than a metal object to test
pinprick sensation
33
 CMED 400 CLINICAL METHODS D.K NERU

Each of the spinal nerves exits the spinal cord canal between 2 of the
vertebrae. Each then goes to a particular part of the body. Sensory function
is important in that the level of impairment coincides with the level of the
lesion,
sensory function: -
 Light touch using cotton wall stroked gently over the skin.
 Superficial pain using a pin.
 Deep pain by squeezing the acheles tendon.
 Temperature by comparing the appreciation of hot and cold objects.
 Position sense by moving the phalanx of a finger or toe to identify
direction of movement.
 Vibration sense which is the tingling felt when vibrate tuning folk is
applied on bony prominence.
 Appreciation of form e.g. different coin.
 Recognition shapes.
All the dermatones should be examine at a time sensory impulse from the
peripheral are conducted to the spinal cord by different nerves through the
posterior root ganglia and posterior spinal roots. The exact extent of the
cerebral cortex concerned in reception of the sensation is still doubtful.
THE MOTOR FUNCTION
Examination of the motor function includes
 Assessment of strength/power
 Muscle tone
 Muscle bulk
 Coordination
 Abnormal movements
Many of these are examined through careful observation
When neurological disease is not anticipated examination of the motor
function of the limbs is usually limited to excluding muscles wasting and
testing muscle tone and power around the major joints and tendon reflexes
1. Strength –is tested by having the patient resist your forces as you
attempt to move their body part against resistance. This is graded on a
scale of one to 5
2. Muscle bulk is primarily examined by inspection. Symmetry is important
with consideration given to handedness and over all behavior
3. Coordination – is tested as part of sequential movements. Ask the patient
to close the eyes and touch the nose at arm’s length and then repeat the
same with the eyes open.
Lower extremity can be tested by telling the patient to run the heel of one
foot over the spine of the other from ankle joint to the knee. Coordination
means movements of various muscles through cooperation of separate
muscles or groups of muscles in order to accomplish a definite act. Lack of
coordination is called ataxia
4. Muscle tone- may be increased or decreased. Increased muscle tone is
easier to detect. There are 2 patterns of increased muscle tone. Rigidity
and spasticity. This is the state of tension or contraction that is always
found in healthy muscles. Increase in tone is called hypertonia and is due
to upper motor neuron lesions clasp knife plasticity or clonus or it is due
to extra pyramidal lesions (cog wheel rigidity).Decrease in tone is called
34
 CMED 400 CLINICAL METHODS D.K NERU

hypotonia and is due to lower motor neuron and cerebellar lesions.

Pronate and supinate the wrist a few times
5. ♦ Flex and extend the elbow
6. ♦ Roll the leg, on the bed, between positions of internal and external
rotat
7. The more gently and unobtrusively you grasp the limbs when you move
them, the less your results will be confused by voluntary movement on
the part of the patient
8. MUSCLES POWER
There are six grades of muscles power.
Grades 0 – complete paralysis.
Grade 1 – there is presence of muscles flicker.
Grade 2 – there is movement with elimination of gravity.
Grade 3 – movement against slight resistance.
Grade 5 - normal power.

9. REFLEXES
There are two types of reflexes normally tested.
a) superficial reflexes
b) deep reflexes
SUPRFICIAL
i) Corneal reflex – there is rapid closure of the eye when one attempts to
touch it. This relies on the ophthalmic branch of trigeminal nerve and the
facial nerve.
ii) Abdominal reflex – these rely on the pyramidal traits. They therefore
disappear if the pyramidal tracts one is affected. They are normally absent
in:
 Obese patients
 Grand multipara
 The tiderly
iii) Cremasteric reflex – strike the skin at the upper and inner part or thigh.
The testicle on that side drains up. This depends on L1 & L2 segments.
iv) Babinskis sign (exterior response)
Strike the sole of the first from the midline all round. The foot responds by
extension and spreading of the toes.
DEEP REFLEXES
1. Triceps triceps tendon – flex the elbow and then tap the triceps
between tendons just above the olecranon. The triceps muscles
contract. This is due to inervation of the 6th & 7th cernical segment.
2. Biceps reflex – the elbow is flexed at right angle and the forearm
placed semipronated position. The examiner places the thumb on the
biceps tendon and skills it with the patella hammer. The biceps
contracts, this is due to inervation by 5th & 6th cervical.
3. Patella tendon reflex – it consists of contraction of the quadriceps
extensor when the patella tendon is tapped. It is due to L2 L3 L4.
4. Achilles tendon reflex – place the foot so that it has averted and
slightly flexed. Dorsiflex the foot to stretch the achilles tendon and
then tap the posterior surface. A contraction of calf muscles result.
This depends on S1 & S2.
35
 CMED 400 CLINICAL METHODS D.K NERU

TEST CO-ORDINATION
Perform a few simple tests of co
Technique ; Ask them to tap on the cover of a book with the fingers of the
other, and then repeat with the other hand. They should do so rhythmically,
with constant force and equally with both hands. ; Then perform rapid
alternating movements, by having them slap the book alternately with the
front and the back of the hand. Ask them to do so fast.; Perform the finger-
nose test. Sit your patient up, hold your finger an arm's length from them,
point with your other hand to their index finger and say; "Put that finger on
my finger Then say: "Put that same finger on your nose." Repeat with your
finger held in another position and then with the other hand. Look for past
pointing and for intention tremor. I there is any difficulty with either of these
tests, proceed to the heel- knee test
SIGN OF MENIGEAL IRRITATION
1. Neck Stiffness
The examiner places his hand behind the patient’s occiput and flexes the
head so that the chin touches the chest. Normally, there is no pain but, in
meningitis there is pain and rigidity.
2. Kerning’s sign:
Passive movement of extending the patients knee when his hip is fully
flexed. The test causes pain and irritation of the hamstrings in menigeal
irritation. These two tests causes reflex muscular spasms due to stretching
of the spinal nerves roots in menigies.
3. Brudzinskis sign
It is used in patients with sciatica. The sciatic nerve and its components are
stretched by passively elevating the patients extended leg with the
examiners hand which is placed behind the heel.
TOPIC EIGHT: SUMMARISING A CASE
When formally presenting a case to colleagues, one provides sufficient
information for them 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. For instance, a student
may describe the patient they have seen to their tutor, or a registrar may
have to bring a consultant up to date on a patient seen previously. It is
possible to do this quickly, elegantly and efficiently with a little thought;
conversely, an unstructured description is likely to be wordy, confusing and
unhelpful.
HOW TO SUMMARISE YOUR CASE
♦ Give your patient’s name, age and sex, and where appropriate, race and
area of residence.
I saw Mr Smith, a 45 year old man living in Seaview.
♦ List the factors which have predisposed to their current illness - such as
relevant medical history or exposure to pernicious factors such as smoking.
Keep this brief and relevant.
He has smoked 20 cigarettes a day for 40 years and has been in hospital
with pneumonia three times this year.
36
 CMED 400 CLINICAL METHODS D.K NERU

♦ Now give only the most relevant details of one or two more important
presenting symptoms and physical signs as well as the diagnosis or
provisional diagnosis.
He presented with fever, cough and severe shortness of breath and I found
clear signs of consolidation in his chest. I diagnosed a lobar pneumonia. This
is confirmed on chest Xray.
♦ In one or two sentences, bring the audience up to date with the patient’s
further course.
He has been treated with intravenous penicillin and is improving rapidly. We
intend discharging him tomorrow
TOPIC NINE :ORDERING OF INVESTIGATIONS
Laboratory examinations in surgical patients have the following objectives:
1. Screening for asymptomatic disease that may affect the surgical result
(eg, unsuspected anemia or diabetes)
2. Appraisal of diseases that may contraindicate elective surgery or require
treatment before surgery (eg, diabetes, heart failure)
3. Diagnosis of disorders that require surgery (eg, hyperparathyroidism,
pheochromocytoma) 4. Evaluation of the nature and extent of metabolic or
septic complications
5. The purposes for which tests are obtained have a great deal to do with
both the choice of diagnostic test and its interpretation.
One survey of physicians in a large teaching hospital found that three
general reasons accounted for most laboratory test ordering: diagnosis
(37%), monitoring therapy (33%), and screening for asymptomatic disease
(32%).
 Ordering and interpreting diagnostic tests are fundamental skills.
Surprisingly, however, evidence indicates that many of us are poorly
trained in this vital area. Studies have shown that physicians
commonly order more laboratory tests than required, use them for the
wrong purposes, and ignore or misinterpret their results. While these
errors have obvious implications for the quality of patient care, there
are large socioeconomic implications as well. Diagnostic tests
obviously add up to significant expenditures
Purpose I: Diagnosis
In order to use a test for diagnostic purposes, the test has to be positive in
a large proportion of patients with the disease (high sensitivity) and
negative in a large proportion without the disease (high specificity). Ideally,
for the test to be maximally useful for diagnostic use, both sensitivity and
specificity should be 100%. One might say that there are two basic
diagnostic uses for laboratory tests. The first is when you wish to rule out a
disease absolutely and the second when you wish to confirm it.
Examining these purposes more closely allows you to identify test
characteristics necessary for each use. In order to be absolutely sure a
patient does not have a disease (ruling it out), falsely negative tests have to
be minimized, so a test with high sensitivity should be used
 negative tests have to be minimized, so a test with high sensitivity
should be used
Purpose 2: Monitoring Therapy

37
 CMED 400 CLINICAL METHODS D.K NERU

Examples of this use for diagnostic tests abound. Whenever a test is

repeated in order to follow a therapeutic drug level or observe for side
effects, it is being used for monitoring purposes
Purpose 3: Screening
The object of the use of diagnostic tests for screening is to detect disease in
its earliest, pre symptomatic state when, presumably, it is less widespread
and more easily treated or cured. Most screening programs, such as stool
occult blood screening or mammography, are aimed at cancer detection,
although other screening programs exist for disorders such as glaucoma,
hypertension, or diabetes
TOPIC TEN: PRESCRIPTION WRITING
A prescription is a tangible measure of a clinician’s therapeutic knowledge. A
high degree of misinterpretation and non - compliance with prescription
directions exists. Instructions in prescription writing are often cursory, with
little corrective feedback for poor practices. The patient rarely complains of
poorly communicated directions.
Prescription writing should therefore be well thought a bout and should
provide comprehensive information as much as possible. It should follow a
definite pattern with the patient’s name, age, address and the date of the
prescription clearly written. The drug name is written clearly and the dosage
specified. The number of units and dosage form e.g. tablets, capsules,
syrups, passaries, suppositories e.t.c. should be clear to the pharmacists
preferably without abbreviations or jargons. The clinician should then sign
the prescription write and a rubber stamp applied.
Clinicians are expected to be familiar with the medical jargons and
abbreviations use internationally.
The following are some of them.
1. Dosage Form
 Syrup – liquid medicine taken by mouth.
 Tablets (tabs) – compounded medicine not encapsulated and
usually taken by mouth.
 Capsules (caps) – powder which is encapsulated usually taken by
mouth.
 Suppositories (supp) – preparations either in tablets or capsules
form for insertion into the rectum.
NB: some tablets use orally can also be inserted through rectum.
 Pessaries – these are pellets or tablets inserted through the vagina.
 Cream/lotion – thick fluidy preparation which is applied on the skin.
 Gutt – liquid preparation for the eyes and ears.
2. Abbreviations used for routes of administration of drugs.
P.O – per oral – takes through the mouth.
I.M – intra – muscular – drugs given by injection into the muscles
I.V – intra – Venus – rugs given through the vein.
Sublingual – apply under the tongue.
Per – rectum – drugs given through the rectum.
Intra-dermal – injections given under the dermis.
S/C – subcutaneous - given under the fat (cutaneous) tissues.
3. Abbreviations indicating the timing and frequency of taking
drugs.
38
 CMED 400 CLINICAL METHODS D.K NERU

O.D – once daily i.e. drug taken one time in 24 hrs.

B.D or BID – twice a day i.e. after every 12 hrs.
TID or TDS – thrice in a day i.e. after every 8 hrs.
QID or QDS – four times a day i.e. after every 6 hrs.
PRN – give the drugs when necessary.
Nocte – given only at night.
4. Symbols use on preservations.
- Treatment

- Diagnosis
COMMON PROBLEMS AND ERRORS
Identification data
The patient address is rarely written by prescribers and is often sought for
identification by the pharmacists. Dating the prescription help the
pharmacist to detect outdated ones. The patient’s age helps the pharmacists
to identify variations in dosage and other factors.
Drug name
Drugs may be prescribed by their generic name which bears the molecule of
the drug or by their brand (original) name. It is important to indicate which
group or drug the clinician means. Sometimes R sign is used to indicate a
brand name. if the same name exists in generic form when a drug product is
marketed by more than one manufacturer, the use of nonproprietary or
generic name leaves the choice of product to the pharmacist.
Prescribers should us only those generics that have been verified by the
Kenya Bureau of Standards. The cost of generic may be low but, the
efficiency could be equally low eventually leading to resistance.
Using the non-proprietory (generic) name of a drug and specifying a
manufacturer has been suggested, but many prescribers do not know the
manufacturer of even popular drugs.
Abbreviations of drug names should be avoided; the use of chemical
notations is often confusing and should be avoided.
If a brand name is used it should be carefully written because many are
similar and confusing. A hastily ornade might be read as orinase or even
ananase. The specific brand name is necessary to use a pre-compounded
combination product.
Dosage
Prescriptions should be given in the metric system.
For tablets and capsules, the terms “grams” or “milligram” other than the
number of tablets or capsules should be used. If one knows that 5ml of the
liquid contains the unit dose, the number of doses desired can be calculated
an exact quantity should be written on prescription.
The number of units dispensed is determined in variety of ways. One may
order a small supply because this will remind the patient to return for follow
up.
A large supply of drugs may also be dangerous because of suicidal or
accidental over dose. However, in chronic cases, large units of drugs may be
dispensed giving firm instructions on their usage.
LABELLING AND DIRECTION

39
 CMED 400 CLINICAL METHODS D.K NERU

Abbreviation should be avoided as much as possible. They may be confusing

even when written clearly. Label directions to the pharmacist so that they
may transcribe directly without translation. Complete sentences precisely
stated are preferred. If the drug must be taken two or three times daily, the
times should be specified on the prescription since patients are confused by
direction such us “6 hours”.
The relationship of drugs with food should be explained to the patient. All
direction should be explained and should start with an action verb e.g.
take-------------------
Apply------------- place---------------
The frequently used phrase “as directed” is undesirable for liquids;
prescribers have relied over the years with house held measures despite the
non uniformity of table, spoons, teaspoons, droppers and wine glasses.
Ideally a teaspoon equal about 5ml while a tablespoon equal 15mls.

END

40