Clinical Examination and History Taking

• Signs = examination findings - concept of the "clothed patient"
• Symptoms = in the history (about 80% of diagnosis will come from the history)
• Structure of medical history:

  • Presenting complaint
  • What the patient's problem is in their own words
  • History of presenting complaint
  • Needs to be concise but comprehensive (when it started, symptoms, what treatment they've had for it, how the symptoms have progressed, etc.)
  • Chronological
  • Medical history
  • How might things impact treatment
  • Allergies
  • Put 'no KNOWN allergies'
  • If they have allergies, ask what happens when they're exposed - e.g. do you get a rash/feel sick
  • If they don't know what happens (e.g. they've been told they have this allergy by a parent) then write that down too
• Structure of medical history:

  • Drugs
  • Some drugs can have intraoral side effects
  • Family history
  • Social history
  • As a minimum, need to ask about: alcohol intake, smoking history, who the patient lives with (because that could affect when they're going to be discharged), and what job they do (or did if they're retired)
  • Alcohol and smoking are 2 big risk factors for oral cancer
• Pain history:

  • Nature
  • Ache - sharp/dull
  • Burning
  • Crushing
  • Location - does it radiate anywhere
  • Exacerbating/relieving factors
  • Severity - how does it affect the pt's sleep
  • Rate on a scale of 1-10
  • Efficacy of medication - prescribed or otherwise
  • Paracetamol is good for mild-moderate pain, so if it's not effective then the pain is probably more significant
• Common causes of chest pain:

  • Angina/heart disease
  • Heartburn - GORD (gastro-oesophageal reflux disease)
  • Apparently feels quite similar to angina
  • Pleuritic pain eg pulmonary embolism
  • Well-localised chest pain that can be located by pt pointing to it
  • Sharp pain when breathing in
  • Musculoskeletal
  • Others eg secondary to trauma - tension pneumothorax
  • Referred pain from abdomen
• Angina/myocardial infarction/heart attack:

  • Cardiac pain caused by impaired arterial supply to heart muscle, resulting in ischaemia at times of increased myocardial workload (e.g. exercise, workload, stress, anxiety)
  • Differentiation of angina from MI because they can be v similar
  • "Crushing" central chest pain radiating to (usually left) arm/mandible
  • With MI, pain not relieved with GTN (glyceriletrinitrate - a type of vasodilator)
  • MI often also associated with nausea/sweating/light-headedness
• Heartburn - GORD: oesophageal pain caused by regurgitation of gastric acid, often due to a hiatus hernia impairing cardiac sphincter function.
• Pleurisy:

  • Pain from rubbing of inflamed pleural surfaces during respiration
  • Can be secondary to pneumonia, cancer, pulmonary embolus or other inflammatory disorders
  • Usually characterised by a sharp pain in their chest when breathing in that is so severe that is stops them from breathing in properly
  • Can be localised by pointing a single finger, which is helpful
• Pulmonary embolism:

  • Sharp, pleuritic chest pain
  • Check for signs/symptoms of DVT (deep vein thrombosis)/risk factors
• Risk factors for DVT (deep vein thrombosis):

  • A coagulation disorder
  • Smoking - makes the blood more coagulable
  • Immobility - long car journey/flight may cause blood to form a thrombus; limbs not moving (compression socks can help)
  • History of pelvic surgery/tumours
  • Pregnancy
  • Surgery (because of the immobility)
  • High levels of oestrogen eg certain types of contraceptive pill