Sunday, August 10, 2025

Cardiovascular System History taking and Clinical Examination

Cardiovascular History Taking

1. Presenting Complaints (PC)

Document the main symptom(s) with duration.

Chest pain (angina pectoris, myocardial infarction) — ask onset, duration, character, site, radiation, precipitating factors, relieving factors, associated symptoms.
- Why: Chest pain character differentiates angina (exertional, relieved by rest) from MI (prolonged, not relieved by rest).
Dyspnoea (shortness of breath) — classify as NYHA functional class I–IV.
- Why: Severity grading helps assess heart failure progression.
Palpitations (subjective awareness of heartbeat) — ask about onset, regularity, triggers.
- Why: Can indicate arrhythmia (e.g., atrial fibrillation, SVT).
Syncope / presyncope (transient loss of consciousness) — relation to exertion, position.
- Why: May suggest arrhythmia, aortic stenosis, or neurocardiogenic syncope.
Fatigue, weakness (reduced cardiac output symptoms) — duration, daily impact.

2. History of Present Illness (HPI)

Onset & progression — gradual vs. sudden onset symptoms.
Temporal pattern — intermittent, persistent, worsening.
Associated features —
- Orthopnoea (dyspnoea in supine position) — Why: Suggests left-sided heart failure.
- Paroxysmal nocturnal dyspnoea (PND) (sudden nighttime breathlessness) — Why: Due to pulmonary congestion from left heart failure.
- Claudication (pain in legs on walking) — Why: Indicates peripheral arterial disease.
Triggering / relieving factors — exertion, emotional stress, rest, medications.

3. Past Medical History (PMH)

Hypertension (HTN) — Why: Risk factor for CAD, heart failure, stroke.
Diabetes mellitus (DM) — Why: Accelerates atherosclerosis.
Dyslipidaemia — Why: Promotes plaque formation in coronary arteries.
Rheumatic fever — Why: Leads to valvular heart disease.
Previous myocardial infarction, angina, heart surgery — Why: Guides prognosis and therapy.

4. Drug History

Cardiac drugs (beta-blockers, ACE inhibitors, diuretics, nitrates) — compliance, side effects.
Anticoagulants / antiplatelets — risk of bleeding vs. thromboembolism prevention.
Recent new medications — can cause drug-induced arrhythmias or fluid retention.

5. Family History

Sudden cardiac death — Why: May indicate inherited arrhythmia syndromes (e.g., long QT, HCM).
Ischaemic heart disease — early onset in family increases risk.
Cardiomyopathy — genetic forms possible.

6. Personal & Social History

Smoking (tobacco use) — Why: Major modifiable risk factor for CAD, PAD.
Alcohol intake — excess causes cardiomyopathy and arrhythmias.
Physical activity level — helps assess functional capacity.
Dietary habits — high salt intake worsens hypertension, heart failure.
Occupational stress — chronic stress linked to hypertension and CAD.

7. Systemic Review (Focused Cardiovascular)

Ask for symptoms in other systems that may indicate cardiovascular cause or complication:

Respiratory — cough, haemoptysis (pulmonary congestion, mitral stenosis).
Neurological — focal weakness, speech difficulty (embolic stroke from AF).
Gastrointestinal — abdominal pain (mesenteric ischaemia), swelling (hepatic congestion in right heart failure).

8. Summary & Clinical Correlation

At the end, link the symptoms and risk factors to possible differentials:

Angina + risk factors + exertional onset → likely stable coronary artery disease.
Dyspnoea + orthopnoea + PND + leg swelling → suggests congestive heart failure.
Palpitations + syncope + irregular pulse → think atrial fibrillation with possible embolic risk.

Step‑by‑step Cardiovascular System Examination

Preparation & safety

Explain procedure & obtain consent [consent = patient’s informed agreement after explanation].
Chaperone present [chaperone = third person (nurse/colleague) present for patient comfort and safety].
Ensure patient is comfortable & exposed from neck to mid‑abdomen (drape otherwise).
Record vital signs: heart rate [beats per minute], blood pressure (BP) [arterial pressure measured in mmHg], respiratory rate [breaths per minute], temperature, SpO₂ [peripheral oxygen saturation].
Position patient sitting and supine (30–45°) as needed for different parts of exam.
Warm your hands and stethoscope.

1) General inspection (from end of bed / on entry)

Overall appearance & distress — signs of dyspnoea [difficulty breathing], cyanosis [bluish lips/tongue from low oxygen].
Cachexia [severe weight loss/wasting] or obesity.
Facial signs: xanthelasma [yellowish cholesterol deposits around eyelids], facial pallor [pale face from anemia].
Neck: visible pulsations (e.g., jugular venous distension).
Chest: surgical scars, chest wall deformities (pectus excavatum/carinatum) — may affect examination.

2) Hands & peripheral signs

Temperature & colour of hands — cool/clammy suggests poor perfusion.
Capillary refill time [time for blanched nail bed to regain colour; >2 sec suggests poor perfusion].
Clubbing [bulbous enlargement of fingertips] — chronic hypoxaemia or infective endocarditis sequelae.
Peripheral cyanosis [blue fingertips/toes] vs central cyanosis [tongue/lips].
Signs of infective endocarditis:
- Osler’s nodes [tender subcutaneous nodules on fingers/toes],
- Janeway lesions [painless erythematous macules on palms/soles],
- Splinter haemorrhages [linear nail bed haemorrhages].
Xanthoma/xanthelasma [cholesterol deposits] — hyperlipidaemia risk.

3) Carotid pulse & neck veins

Carotid pulse palpation (one side at a time): assess rate, rhythm, volume (bounding/weak) and character (brisk, delayed).
- Bounding pulse [large volume] — e.g., thyrotoxicosis, aortic regurgitation.
- Slow rising (brachycardic) pulse — severe aortic stenosis.
Carotid bruit [whooshing sound over artery heard with stethoscope] — suggests carotid artery stenosis (atherosclerosis).
Jugular venous pressure (JVP) measurement: patient at 30–45°; identify internal jugular venous pulsation (soft, non‑palpable), measure vertical height above sternal angle (normal ≤ 3 cm) — elevated JVP indicates right‑sided heart failure/fluid overload.
- Hepato‑jugular reflux [sustained rise in JVP when firm pressure applied to liver] — supports right heart failure/volume overload.

4) Precordial inspection (anterior chest)

Look for visible pulses / abnormal movement: precordial impulse, visible heaves.
- Precordial (apical) impulse / PMI [point of maximal impulse felt on chest wall] — normally 5th intercostal space (ICS), mid‑clavicular line (MCL).
- Displacement of PMI (lateral/downwards) → cardiomegaly [enlarged heart].
- Parasternal heave (lift) [sustained outward movement felt under hand] — right ventricular enlargement/pressure overload (e.g., pulmonary hypertension).

5) Palpation (systematic)

Palpate apex beat (PMI): location, size, amplitude, duration.
- Hyperdynamic, displaced PMI → ventricular enlargement or volume overload.
Palpate left parasternal area for heave [sustained outward impulse] (RV enlargement).
Palpate for thrills [palpable vibration over chest produced by severe murmurs] — if present, localize.
Palpate epigastrium for hepatic pulsation (tricuspid regurgitation / severe regurgitant lesions).
Assess peripheral pulses: radial, brachial, femoral, dorsalis pedis, posterior tibial — compare rate, rhythm, symmetry, volume (e.g., femoral delay in coarctation/aortic dissection).

6) Percussion (brief)

Cardiac percussion to estimate cardiac size (less used than imaging): percuss from left chest to detect dullness change from lung to heart — rough guide to cardiomegaly.
- (Note: chest X‑ray / echocardiography are preferred for accurate heart size.)

7) Auscultation — method & landmarks

Use diaphragm (for high‑pitch sounds) and bell (for low‑pitch sounds) of stethoscope.
Systematically auscultate with patient sitting leaning forward (for left‑sided/diastolic murmurs) and supine / left lateral decubitus (for mitral sounds).
Auscultation points (landmarks):
- Aortic area: 2nd right ICS, sternal border.
- Pulmonic area: 2nd left ICS, sternal border.
- Erb’s point: 3rd left ICS, sternal border (useful for S2 and some murmurs).
- Tricuspid area: 4th–5th left ICS, sternal border.
- Mitral (apex) area: 5th ICS, mid‑clavicular line (PMI).

8) Heart sounds — what to listen for (definitions included)

S1 (first heart sound) [closure of mitral & tricuspid valves at start of systole] — loud/soft variations.
S2 (second heart sound) [closure of aortic & pulmonic valves at the end of systole]; split S2 [physiological or pathological splitting of aortic and pulmonary components during inspiration].
S3 (third heart sound) [low‑pitched early diastolic sound after S2] — indicates increased volume/ventricular failure in adults (pathological); in young may be physiological.
S4 (fourth heart sound) [late diastolic sound just before S1] — due to atrial contraction against a stiff ventricle (left ventricular hypertrophy, ischemia).
Pericardial rub [scratching/pleural‑like sound] — suggests pericarditis [inflammation of pericardium].

9) Murmurs — classification & common patterns (with definitions)

Murmur [abnormal sound caused by turbulent blood flow across valves or defects] — characterize by timing (systolic/diastolic/continuous), shape (crescendo, decrescendo, holosystolic/pansystolic), location, radiation, intensity (grade I–VI), pitch and response to manoeuvres.

Common examples:

Aortic stenosis (AS): harsh systolic ejection murmur at aortic area, radiates to carotids; slow‑rising (parvus et tardus) carotid pulse.
Mitral regurgitation (MR): pansystolic (holosystolic) murmur best heard at apex, radiates to axilla [armpit].
Aortic regurgitation (AR): early decrescendo diastolic murmur best heard at left sternal edge; bounding pulse (water‑hammer) may be present.
Mitral stenosis (MS): mid‑diastolic rumble with opening snap [high‑pitched sound immediately after S2 when stenotic mitral valve opens]; best at apex with patient in left lateral position.
Tricuspid regurgitation (TR): pansystolic murmur at left lower sternal border, increases with inspiration.
Ventricular septal defect (VSD): harsh pansystolic murmur at left sternal border, often loud.

10) Dynamic manoeuvres (definitions + typical effects)

(Use in cooperative, stable patients only.)

Inspiration [breathing in] — increases right‑sided murmurs (more venous return).
Expiration / leaning forward — accentuates left‑sided murmurs and AR/AS.
Valsalva manoeuvre (strain phase) [forced expiration against closed glottis → reduces venous return] — most murmurs decrease, but hypertrophic obstructive cardiomyopathy (HOCM) murmur increases.
Handgrip [patient squeezes hand → increases afterload] — increases intensity of MR/TR/AR murmurs, decreases intensity of AS and HOCM murmurs.
Squatting / passive leg raise [increases venous return & afterload] — increases AS, MR murmurs; decreases HOCM murmur.
Standing from squatting [decreases venous return] — increases HOCM murmur; decreases AS and MR.

(Clinical correlation: use these changes to help identify murmur origin — e.g., HOCM vs AS.)

11) Peripheral vascular & volume status assessment

Peripheral pulses: compare radial/femoral pulses (delay in femoral suggests coarctation/aortic obstruction).
Ankle‑brachial index (ABI) [ratio of ankle to brachial systolic BP] — assesses peripheral arterial disease.
Peripheral oedema [pitting vs non‑pitting] — scale 1+ to 4+; bilateral pitting → heart failure; unilateral → DVT/local cause.
Liver size & tenderness: hepatomegaly [enlarged liver] in chronic right heart failure (congestive hepatopathy).
Ascites [fluid in peritoneal cavity] — may occur in advanced right heart failure.

12) Bedside investigations & when to request

ECG (electrocardiogram) [records cardiac electrical activity] — arrhythmias, ischaemia, prior MI.
Chest X‑ray (CXR) [radiograph] — cardiac size, pulmonary oedema, vascular congestion.
Echocardiography (ECHO) [ultrasound of heart] — valve function, chamber size, wall motion, ejection fraction.
BNP/NT‑proBNP [blood markers of cardiac stretch] — suggest heart failure.
Cardiac enzymes (troponins) — for acute coronary syndrome.
Carotid duplex / CT angiography — for suspected carotid stenosis/aortic disease.

13) Red flags / urgent findings

New loud systolic murmur with hypotension/acute pulmonary oedema → possible acute MR (papillary muscle rupture) or large MI complication — urgent cardiology/surgical review.
Syncope with exertion + systolic murmur → suspect severe aortic stenosis — urgent evaluation.
Worsening orthopnoea, rising JVP, hypoxia → acute heart failure/pulmonary oedema — immediate management.
Unequal BP in arms (difference >20 mmHg) or sudden severe chest/back pain → suspect aortic dissection — emergency.

14) Documentation checklist (concise)

Consent & chaperone. Vitals. General impression. JVP (measured height). Carotid findings. PMI location & character. Presence of heave/thrill. Murmurs: timing, location, radiation, grade, effect of manoeuvres. Peripheral pulses (rate/volume/symmetry). Peripheral oedema and hepatomegaly. Impression & immediate plan (ECG, CXR, ECHO, labs, urgent referrals).

Quick clinical correlations (one‑line reminders)

Raised JVP + hepatomegaly + peripheral oedema → right‑sided heart failure / cor pulmonale.
Displaced, diffuse PMI → left ventricular enlargement (dilated cardiomyopathy).
Loud S3 in adult → systolic heart failure (volume overload).
Systolic murmur radiating to carotids + slow rising pulse → severe aortic stenosis.
Pansystolic murmur at apex radiating to axilla → mitral regurgitation.

Respiratory System History Taking and Clinical Examination

RESPIRATORY SYSTEM — HISTORY TAKING

1. Patient Demographics

Name, Age, Sex, Occupation, Address
- Why relevant:
  - Age: Bronchiolitis (infants), asthma (children/young adults), COPD/lung cancer (older adults)
  - Sex: Smoking-related lung disease more common in men (but rising in women); autoimmune-related lung disease more in women
  - Occupation:
    - Coal miner → pneumoconiosis
    - Cotton mill worker → byssinosis
    - Farmer → hypersensitivity pneumonitis
  - Address: Endemic TB areas, industrial pollution zones, high altitude (chronic mountain sickness)

2. Chief Complaint(s) with Duration

Examples:

Cough × 2 weeks
Breathlessness × 3 days
Chest pain × 5 hours
Hemoptysis × 1 week

Duration distinguishes acute (e.g., pneumonia, asthma attack) from chronic (e.g., COPD, bronchiectasis) conditions.

3. History of Presenting Illness

A. Symptom Analysis (with connections)

1. Cough

Onset:
- Sudden → aspiration, pulmonary embolism
- Gradual → TB, chronic bronchitis
Duration:
- Acute (<3 weeks) → URTI, pneumonia, acute bronchitis
- Chronic (>8 weeks) → TB, COPD, asthma, bronchiectasis, lung cancer
Character:
- Dry → viral infections, interstitial lung disease, ACE inhibitor use
- Productive → bacterial pneumonia, chronic bronchitis, bronchiectasis
Sputum:
- Mucoid → asthma, COPD
- Purulent (yellow/green) → bacterial infection
- Rusty → pneumococcal pneumonia
- Pink frothy → pulmonary edema
- Foul-smelling → anaerobic infection, lung abscess, bronchiectasis
Timing:
- Nocturnal → asthma, left heart failure
- Morning → chronic bronchitis
Triggers: cold air, exercise, allergens (asthma)

2. Breathlessness (Dyspnea)

Onset:
- Sudden → pulmonary embolism, pneumothorax, acute asthma
- Gradual → COPD, ILD, heart failure
Duration & Progression: Worsening over days (pneumonia) vs years (COPD)
Severity:
- NYHA grading (I–IV) or mMRC scale for chronic cases
Relation to posture:
- Orthopnea → heart failure
- Platypnea → hepatopulmonary syndrome
- Trepopnea → unilateral lung disease
Associated symptoms: Wheeze (asthma/COPD), chest pain (PE, pneumonia), cough (multiple causes)

3. Chest Pain

Site: Localized vs diffuse
Character:
- Sharp, pleuritic (worse on deep breath) → pleurisy, pneumonia, PE
- Dull/pressure → myocardial ischemia (needs cardiac evaluation)
Radiation:
- To shoulder → diaphragmatic irritation
- To back → aortic dissection (emergency)
Relation to respiration: Pleuritic pain increases with inspiration/cough

4. Wheezing / Noisy Breathing

Expiratory wheeze: asthma, COPD
Inspiratory stridor: upper airway obstruction, foreign body, tumor

5. Hemoptysis

Amount: Streaks vs massive (>200–600 mL/24h)
Color/character: Bright red (bronchiectasis, TB, carcinoma), frothy (pulmonary edema), clots (bronchiectasis, tumor)
Onset: Single episode vs recurrent
Associated: Fever (TB, pneumonia), weight loss (malignancy), night sweats (TB)
Differentiate from hematemesis (GI bleed) — history & examination

6. Fever

Low-grade + night sweats: TB
High-grade + chills: pneumonia, lung abscess, empyema
Relapsing: malaria (if splenic enlargement with respiratory signs)

7. Other Respiratory Symptoms

Hoarseness: recurrent laryngeal nerve palsy (lung apex tumor), laryngitis
Clubbing: chronic suppurative lung disease, lung cancer, ILD
Cyanosis: hypoxemia (COPD, pneumonia)
Swelling of face/neck: SVC obstruction from lung cancer

4. Associated Symptoms (Other systems)

Cardiovascular: palpitations, chest discomfort (pulmonary hypertension)
GI: reflux symptoms (GERD causing cough)
Neuro: weakness (hypoxia-related), headaches (CO₂ retention)

5. Past History

Childhood asthma
Pulmonary TB
Hospitalizations for pneumonia, COPD exacerbation
Occupational lung disease
Allergic rhinitis, atopy
Blood transfusions (HIV, hepatitis — relevant for TB risk)

6. Personal History

Smoking:
- Type: cigarette, bidi, hookah
- Pack-years = (cigarettes per day ÷ 20) × years smoked
- Smoking → COPD, lung cancer, chronic bronchitis
Alcohol: aspiration risk if intoxicated
Diet: malnutrition → low immunity → TB risk
Pets/birds: psittacosis, hypersensitivity pneumonitis
Travel: COVID-19, TB, influenza exposure

7. Family History

TB contact
Asthma/allergic diseases
Cystic fibrosis

8. Drug History

ACE inhibitors (dry cough)
Amiodarone, bleomycin (pulmonary fibrosis)
Beta-blockers (bronchospasm in asthma)

9. Socioeconomic & Environmental History

Crowded housing (TB spread)
Occupational dust/fumes
Indoor smoke from cooking

10. Immunization History

BCG (TB prevention in childhood)
Influenza & pneumococcal vaccines (for elderly, chronic lung disease)

Step-by-step Respiratory System Examination

1) Preparation & safety

Explain the procedure & obtain consent [consent = patient’s informed permission after explanation].
Chaperone present [chaperone = third person (nurse/colleague) present during intimate exams for comfort/protection].
Wash hands, warm stethoscope, ensure good lighting and privacy.
Record vital signs: pulse [heart beats per minute], blood pressure [arterial pressure], respiratory rate [breaths per minute], temperature [body heat], SpO₂ [peripheral oxygen saturation measured by pulse oximeter].

2) General inspection (while patient sits or on entry)

Work of breathing / respiratory distress [use of accessory muscles or visible effort to breathe] — look for intercostal/substernal retraction [skin sinking between ribs/below sternum on inspiration], nasal flaring [nostrils widen on inspiration].
Respiratory rate & pattern [rate = breaths/min; pattern = regular/irregular, e.g., Cheyne–Stokes (periodic waxing/waning of respirations) or Kussmaul (deep, laboured breathing)].
Body habitus / nutrition: cachexia [severe weight loss/wasting] seen in chronic disease/TB/cancer.
Cyanosis [bluish discoloration of lips/tongue from low arterial oxygen] — central (tongue/lips) vs peripheral (fingers).
Clubbing [bulbous enlargement of fingertips and loss of the normal nail angle] — suggests chronic suppurative lung disease/ILD/bronchiectasis/cancer.
Cough / sputum: note if patient is actively coughing; character of sputum if expectorated (mucoid/purulent/foul/hemoptysis).
Facial/neck swelling or distended neck veins → consider superior vena cava syndrome [obstruction of SVC causing venous congestion].

3) Hands & peripheral signs

Finger clubbing (inspect/Schamroth’s window test) [absence of the diamond-shaped space when dorsal nail beds opposed].
Peripheral cyanosis [bluish fingers/toes], cool peripheries (poor perfusion).
Asterixis [flapping tremor of outstretched hands] suggests CO₂ retention/hepatic encephalopathy (in severe chronic respiratory failure).
Capillary refill time [time for blanched nail bed to return colour; >2s suggests poor perfusion].

4) Face, mouth, nose, throat (upper airway)

Nasal mucosa & sinuses: discharge/obstruction/polyps — allergic rhinitis/sinusitis.
Oral cavity & oropharynx: look for tonsillar enlargement/exudates (tonsillitis), oral thrush (immunosuppression).
Voice quality (hoarseness) [change in voice] — recurrent laryngeal nerve palsy, laryngeal disease.
Stridor [high-pitched inspiratory sound] → upper airway obstruction (laryngeal edema, foreign body, tracheal lesion).
Palpate cervical lymph nodes [lymph gland enlargement] — tender (infective), firm/fixed (malignancy/TB).

5) Neck & central checks

Tracheal position: midline vs deviated — deviation towards collapse/fibrosis; away from large effusion/tension pneumothorax.
Jugular venous pressure (JVP) [height of venous column seen in neck] — raised in right heart failure; observe for Kussmaul’s sign [paradoxical rise in JVP on inspiration].
Thyroid (if relevant) — goitre causing compression.

6) Chest inspection (anterior, lateral, posterior)

Chest shape: barrel chest [increased AP diameter, seen in emphysema/COPD].
Surgical scars, tracheostomy, stomas.
Asymmetry of chest expansion [one side moves less than the other] — suggests consolidation, effusion, collapse, pneumothorax, or pain limiting movement.
Accessory muscle use (sternocleidomastoids, scalene) on inspiration — severe airflow limitation.
Respiratory excursion [measure of movement—usually with hands/mark on posterior ribs at T10] — reduced in pleural effusion, lobar consolidation, diaphragmatic paralysis.

7) Palpation (systematic)

Chest expansion: place hands laterally on lower ribs with thumbs midline; ask deep inspiration — compare both sides.
- Reduced expansion = pleural effusion, lobar collapse, pain.
Tactile (vocal) fremitus [vibration felt on chest wall when patient speaks, e.g., says “ninety-nine”]:
- Increased fremitus = consolidation (pneumonia) [solid lung transmits vibration better].
- Decreased/absent fremitus = pleural effusion/pneumothorax/COPD [air or fluid blocks vibration].
Tracheal tug / mediastinal shift (if palpable).

8) Percussion (systematic, compare side-to-side)

Percussion [tapping the chest to elicit sound] — map resonance across chest.
Resonant [normal hollow note over healthy lung].
Dullness [short, muffled note] → consolidation (lobar pneumonia), pleural effusion, atelectasis [collapse of lung tissue].
Stony dull [very dull, heavy sound] — large pleural effusion.
Hyperresonant / tympanic [loud, hollow note] → pneumothorax (air in pleural space) or hyperinflation (COPD, asthma).
Diaphragmatic excursion [difference in percussion note of diaphragm between inspiration and expiration; reduced in pleural effusion or elevated hemidiaphragm].

9) Auscultation (systematic: posterior → lateral → anterior; compare symmetrical areas)

Use diaphragm of stethoscope; ask patient to breathe normally then deeply through an open mouth.
Vesicular breath sounds [soft, low-pitched, inspiration > expiration] — normal over most lung fields.
Bronchial breath sounds [loud, tubular, expiration ≥ inspiration] — heard over consolidation where air-filled bronchi are adjacent to solid lung (lobar pneumonia).
Reduced/absent breath sounds — massive effusion, pneumothorax, severe emphysema.
Added sounds (adventitious sounds):
- Crackles / rales [brief popping sounds]:
  - Fine crackles = soft, high-pitched at end-inspiration — interstitial fibrosis, pulmonary oedema (early inspiratory/late inspiratory depending on cause).
  - Coarse crackles = louder, lower-pitched — secretions in bronchi (bronchiectasis, resolving pneumonia).
- Wheeze [continuous musical sound, usually expiratory] — asthma/COPD/airway narrowing.
- Monophonic wheeze [single note] → localised airway obstruction (tumour, foreign body).
- Pleural friction rub [creaky/scratchy sound synchronous with breathing] → pleuritis (inflamed pleural surfaces).
Vocal resonance tests (perform if abnormal percussion/auscultation):
- Bronchophony [patient says “ninety-nine”; increased clarity over consolidation].
- Egophony [patient says “eee” but heard as “ay” over area of consolidation/effusion].
- Whispered pectoriloquy [whispered words heard loudly over consolidation].

10) Special manoeuvres & signs (targeted tests)

Peak expiratory flow (PEF) [maximal speed of expiration measured by peak flow meter] — quick assessment of obstructive severity (asthma).
Spirometry [lung function test measuring volumes and flows — FEV₁/FVC etc.] — diagnostic for obstructive vs restrictive disease.
Percussion for pleural effusion: stony dullness at base, shifting dullness on position change [shifting dullness = dull area moves when patient rolls].
Test for pneumothorax: hyperresonance + absent breath sounds + absent fremitus; tension pneumothorax may show tracheal deviation + hemodynamic compromise (hypotension, distended neck veins).
Tests for consolidation: increased fremitus + dull percussion + bronchial breathing + positive egophony/bronchophony.

11) ENT / upper airway focused exam (if indicated)

Flexible nasoendoscopy / indirect laryngoscopy [visualization of nasal passages & larynx] — indicated for persistent hoarseness, stridor or suspected vocal cord palsy. (Refer ENT for procedure.)

12) Peripheral limb / DVT exam (if PE suspected)

Calf/leg inspection & palpation: swelling, erythema, tenderness — consider DVT [deep venous thrombosis], a common source of pulmonary embolism (PE).
Homan’s sign [pain in calf on passive foot dorsiflexion] — historically used but non-specific/unreliable.

13) Bedside adjuncts to support findings

Pulse oximetry [noninvasive SpO₂] — hypoxia if <90% (depends on clinical context).
Arterial blood gas (ABG) [blood test measuring PaO₂, PaCO₂, pH] — for respiratory failure/hypercapnia assessment.
Chest X-ray (CXR) [radiographic imaging] — consolidation, effusion, collapse, pneumothorax.
Ultrasound chest [bedside imaging] — detect pleural effusion, guide thoracentesis [pleural fluid aspiration].
Sputum tests: Gram stain/culture, AFB smear/culture for TB, PCR panels as indicated.
D-dimer / CTPA [CT pulmonary angiography] — in suspected pulmonary embolism per clinical probability.

14) Mapping common signs → likely causes (quick clinical pocket)

Increased fremitus + dull percussion + bronchial breathing + egophony → lobar consolidation (pneumonia).
Decreased fremitus + stony dullness + reduced breath sounds → pleural effusion.
Hyperresonance + absent fremitus + absent breath sounds → pneumothorax.
Diffuse hyperresonance + quiet chest sounds → emphysema/COPD (hyperinflation).
Fine bibasal end-inspiratory crackles + clubbing → pulmonary fibrosis / interstitial lung disease.
Polyphonic expiratory wheeze + prolonged expiration + reversibility with bronchodilator → asthma.
Foul-smelling sputum + localized coarse crackles + recurrent infections → bronchiectasis / lung abscess.

15) Red flags — act immediately

Severe respiratory distress (use of accessory muscles, inability to speak in full sentences).
SpO₂ persistently <90% despite oxygen [hypoxaemia].
Tension pneumothorax (sudden severe dyspnea, hypotension, tracheal deviation, unilateral silent chest) — emergency decompression.
Massive hemoptysis (large volume bleeding into airways) — secure airway and urgent haemoptysis protocol.
Suspected pulmonary embolism with hemodynamic instability — urgent thrombolysis/ICU as per local protocol.

16) Documentation template (concise for notes / OSCE)

Consent/chaperone present. Vitals: RR, SpO₂, T, HR, BP.
General: distress, RR pattern, cyanosis, clubbing present/absent.
ENT/neck: tracheal position, JVP, nodes.
Chest: inspection (symmetry, scars), palpation (expansion, fremitus), percussion (notes and areas), auscultation (breath sounds, added sounds; egophony/bronchophony if done).
Peripheral: signs of DVT, asterixis if present.
Impression: e.g., “Findings consistent with right lower lobe consolidation (↑ fremitus, dullness, bronchial breathing); plan CXR, sputum cultures, start empiric antibiotics after senior review.”
Urgent actions if red flags present.

Gastrointestinal System (GIT) History Taking and clinical examination

Gastrointestinal System (GIT) History Taking and clinical examination

GASTROINTESTINAL SYSTEM HISTORY TAKING

1. Patient Demographics

Name, Age, Sex, Occupation, Address
- Why relevant:
  - Age: Infantile hypertrophic pyloric stenosis (infants), appendicitis (children), gallstones/peptic ulcer (adults), malignancy (elderly)
  - Sex: Gallstones more in females, alcoholic liver disease more in males
  - Occupation: Chemical exposure (liver disease), sedentary lifestyle (constipation)
  - Address: Endemic hepatitis A/E areas, cholera outbreaks

2. Chief Complaint(s) with Duration

State in patient’s words, then translate to medical terms.
- Example: “Pain in upper stomach since 3 days” → “Epigastric pain × 3 days”
- Clinical relevance: Duration helps differentiate acute (e.g., acute appendicitis) from chronic (e.g., peptic ulcer disease) conditions.

3. History of Presenting Illness

A. Symptom Analysis (SOCRATES / OLD CARTS)

1. Abdominal Pain

Location:
- RUQ → Acute cholecystitis, hepatitis
- Epigastrium → Gastritis, peptic ulcer, pancreatitis
- Periumbilical → Early appendicitis, small bowel pathology
- LLQ → Sigmoid diverticulitis, colitis
- Generalized → Peritonitis, gastroenteritis
Onset: Sudden (perforation, ischemia) vs gradual (gastritis, tumor)
Character: Colicky (intestinal obstruction), burning (GERD), dull ache (hepatitis)
Radiation:
- To back → Pancreatitis, posterior penetrating ulcer
- To shoulder → Diaphragmatic irritation (subphrenic abscess)
Relation to meals:
- Pain after meals → Gastric ulcer
- Pain relieved by meals → Duodenal ulcer
Relieving factors: Leaning forward (pancreatitis), vomiting (pyloric obstruction)
Associated symptoms: Vomiting (gastritis), jaundice (hepatitis), fever (cholecystitis)

2. Vomiting

Timing:
- Early morning → Raised ICP or pregnancy
- Immediately after meals → Gastric outlet obstruction
- Hours after meals → Gastroparesis
Content:
- Food particles → Delayed gastric emptying
- Bilious → Obstruction distal to pylorus
- Coffee-ground → Gastric/duodenal ulcer bleed
- Fresh blood → Mallory–Weiss tear, variceal bleed
- Feculent → Distal intestinal obstruction
Frequency: Persistent (gastroenteritis), intermittent (partial obstruction)

3. Altered Bowel Habits

Diarrhea: Acute watery (infective), chronic (>4 weeks → IBD, malabsorption)
Constipation: Functional, hypothyroidism, obstruction (colorectal cancer)
Alternating diarrhea/constipation: IBS, carcinoma colon
Mucus in stools: IBS, amoebic dysentery
Blood in stools:
- Fresh blood → Hemorrhoids, fissure, carcinoma rectum
- Mixed with stool → Colon cancer, ulcerative colitis
- Black tarry (melena) → Upper GI bleed

4. GI Bleeding

Hematemesis:
- Bright red → Varices, gastric ulcer
- Coffee-ground → Gastritis, ulcer bleed
Melena: Peptic ulcer, varices, small bowel tumors
Hematochezia: Lower GI bleed, massive upper GI bleed

5. Jaundice

Onset: Sudden (viral hepatitis), gradual (cholangiocarcinoma)
Associated:
- Dark urine & pale stools → Obstructive jaundice
- Fever + chills → Ascending cholangitis
- Pruritus → Cholestasis

6. Abdominal Distension

Acute: Perforation, obstruction, peritonitis
Chronic: Ascites (cirrhosis, TB peritonitis), tumors
Relation to position: Ascites increases on lying down

7. Dysphagia

Solids only: Esophageal stricture, carcinoma
Solids then liquids: Progressive carcinoma
Liquids > solids: Achalasia cardia
Painful swallowing (odynophagia): Esophagitis

8. Appetite & Weight Changes

Anorexia: Hepatitis, carcinoma stomach
Early satiety: Gastric cancer, ascites
Unintentional weight loss: Malignancy, malabsorption

4. Associated Symptoms

Fever → Typhoid, liver abscess, cholangitis
Fatigue → Chronic liver disease, anemia from GI bleed
Tenesmus → Rectal carcinoma, proctitis
Steatorrhea → Chronic pancreatitis, celiac disease

5. Past History

Peptic ulcer: Risk of recurrence or complications
Jaundice: Recurrent → CBD stones, hemolysis
Hepatitis: Viral hepatitis, autoimmune
GI surgery: Adhesions causing obstruction
Blood transfusions: Hepatitis B/C risk

6. Personal History

Diet: High fat → Gallstones; low fiber → Constipation
Alcohol: Alcoholic liver disease, pancreatitis
Tobacco: Esophageal, gastric cancer
Bowel habits: IBS, hemorrhoids
Water source: Hepatitis A/E, cholera risk

7. Family History

Colon cancer, polyposis syndromes, IBD, Wilson’s disease

8. Menstrual/Obstetric History (Females)

Amenorrhea + abdominal distension: Pregnancy
Menstrual irregularity: PCOS, hypothyroidism-related GI effects

9. Drug History

NSAIDs → Peptic ulcer
Steroids → Masked infection, ulcer
Anti-TB drugs → Hepatitis
Iron → Black stools (benign cause)

10. Socioeconomic & Environmental History

Poor sanitation → Helminthic infestations
Slum living → Hepatitis A/E, cholera
Travel → Typhoid, traveler’s diarrhea

🍽️ Gastrointestinal (GIT) System Examination: Technical Terminology

🪞 1. Inspection (Looking)

Term	Meaning
Scaphoid abdomen	Sunken-in appearance of the abdomen — may be seen in malnutrition or cachexia
Distended abdomen	Swollen abdomen — may indicate gas, fluid, mass, or obstruction
Peristalsis	Visible wave-like movements on the abdomen — seen in intestinal obstruction
Pulsations	Visible throbbing — may suggest abdominal aortic aneurysm
Striae	Stretch marks — seen in obesity, pregnancy, or Cushing’s syndrome
Surgical scars	Previous surgical sites — helpful for history and differential diagnosis
Umbilicus	Normally centrally placed and inverted; everted may suggest ascites or mass
Caput medusae	Dilated tortuous veins around the umbilicus — due to portal hypertension
Jaundice	Yellowish discoloration of the skin/sclera — indicates liver dysfunction
Clubbing	Bulbous enlargement of fingertips — seen in cirrhosis, IBD
Spider angioma	Small red spots with radiating vessels — seen in liver disease
Gynecomastia	Male breast enlargement — can be seen in cirrhosis

✋ 2. Palpation (Feeling)

Term	Meaning
Superficial palpation	Gentle pressing to detect tenderness or rigidity
Deep palpation	Firm pressing to feel deep organs like liver, spleen, kidney
Rebound tenderness	Pain when pressure is suddenly released — indicates peritonitis
Guarding	Involuntary tightening of abdominal muscles — protective reflex in peritonitis
Rigidity	Board-like hardness of abdominal wall — suggests severe peritonitis
Murphy’s sign	Pain on pressing under right costal margin during deep inspiration — indicates cholecystitis
McBurney’s point	One-third from ASIS to umbilicus — tenderness here indicates appendicitis
Rovsing’s sign	Pain in right lower abdomen when pressing on the left — suggests appendicitis
Palpable liver	Normally not felt below costal margin; if palpable — could indicate hepatomegaly
Palpable spleen	Felt below the left costal margin — suggests splenomegaly
Ballotable kidney	Kidney felt between two hands (anterior-posterior) — usually indicates enlargement
Fluid thrill	Wave-like impulse felt — suggests massive ascites
Shifting dullness	Percussion note changes when patient changes position — confirms free fluid (ascites)

🥁 3. Percussion (Tapping)

Term	Meaning
Tympanic note	Drum-like sound — normal over air-filled intestines
Dull note	Flat sound — over solid organs like liver or fluid-filled area (ascites)
Liver span	Measured in midclavicular line — normal: 6–12 cm
Splenic dullness	Normally not percussible; dullness suggests splenomegaly
Shifting dullness	As above; suggests free peritoneal fluid
Fluid thrill	Confirms presence of large volume of ascitic fluid

🎧 4. Auscultation (Listening)

Term	Meaning
Bowel sounds	Normal gurgling sounds every 5–15 seconds
Hyperactive bowel sounds	Loud and frequent — seen in early obstruction or gastroenteritis
Absent bowel sounds	No sound for over 2 minutes — suggests paralytic ileus or late obstruction
Bruits	Whooshing sounds over arteries — suggests turbulent blood flow (e.g., renal artery stenosis)
Succussion splash	Splashing sound heard over the stomach — seen in gastric outlet obstruction

🧠 Other Important Terms

Term	Meaning
Hepatomegaly	Enlarged liver
Splenomegaly	Enlarged spleen
Ascites	Fluid accumulation in the peritoneal cavity
Peritonitis	Inflammation of the peritoneum — often with guarding, rigidity, rebound tenderness
Portal hypertension	Increased pressure in portal vein system — leads to ascites, caput medusae, varices
Hernia	Protrusion of organ/tissue through abdominal wall — seen as bulge
Rectal examination	Digital exam of rectum to check for masses, bleeding, tenderness
Digital rectal exam (DRE)	Using finger to assess rectum and prostate (in males)

🔁 GIT Surface Anatomy Landmarks

Structure	Surface Landmark
Liver	Right hypochondrium, below costal margin
Gallbladder	Intersection of right costal margin and lateral border of rectus muscle
Appendix	McBurney’s point (RLQ)
Spleen	Left hypochondrium, under ribs 9–11
Kidneys	Posterior abdomen, T12–L3 vertebrae area
Stomach	Epigastrium and left upper quadrant

GASTROINTESTINAL EXAMINATION — STEP BY STEP

A. Preparation & basic checks (before you touch the patient)

Explain the exam; obtain consent; ensure privacy and a chaperone if needed.
Ask patient to empty bladder if possible.
Position: supine, arms at sides, knees slightly flexed (relaxes abdominal wall). Also have patient sit/stand when requested (hernia/veins).
Inspect lighting and expose abdomen from nipples to mid-thigh.
Record vital signs: pulse, BP, temperature, respiratory rate, oxygen saturation. (Abnormal vitals = urgent).

B. General inspection & systemic signs (head-to-toe glance)

Inspect the whole patient for systemic signs that point to GI disease:

General appearance — cachexia/wasting → chronic disease, malignancy, IBD.
Skin: jaundice (hepatitis/obstructive jaundice), bruising/spider nevi/palmar erythema (chronic liver disease), xanthelasma (cholestasis/hyperlipidemia), excoriations (pruritus of cholestasis).
Hands: asterixis (flapping) → hepatic encephalopathy; leukonychia/koilonychia → chronic disease/iron deficiency.
Eyes & mouth: conjunctival pallor → anemia from GI bleed; angular stomatitis, glossitis → malabsorption. Fetor hepaticus (distinctive breath) → severe liver failure.
Chest & breasts: gynaecomastia (chronic liver disease), chest wall scars (previous surgery).
Abdomen (quick look): distension, visible peristalsis (obstruction), surgical scars (adhesions), dilated veins (caput medusae → portal hypertension), visible pulsation (AAA).

Why: These signs help triage: e.g., jaundice + pruritus → obstructive cholestasis; weight loss + mass → malignancy.

C. Abdominal examination — correct sequence: INSPECT → AUSCULTATE → PERCUSS → PALPATE

1. Inspect (stand at foot and right side)

Contour: flat, scaphoid, distended (ascites; obstruction).
Scars / stomas / fistulae — note location & type (past surgery, ileostomy).
Striae / pigmentation / bruising (Cushing’s, chronic disease).
Veins: caput medusae (portal hypertension), dilated abdominal wall veins.
Pulsation: epigastric pulsation (AAA if strong & expansile).
Visible peristalsis: suggests small-bowel obstruction.
Masses: visible lumps or hernias on coughing/standing.

Clinical connections: Distension + fluid thrill/shifting dullness → ascites (cirrhosis, malignancy, TB). Visible peristalsis + vomiting → obstruction.

2. Auscultation

Use diaphragm; listen before palpation:
- Bowel sounds: normal (5–35/min).
  - Hyperactive, high-pitched, tinkling → small-bowel obstruction.
  - Hypoactive or absent → ileus or peritonitis (if absent in all quadrants).
  - Borborygmi (loud rumbling) → gastroenteritis, hunger.
- Bruits: listen over aorta, epigastrium, renal arteries, iliac arteries.
  - Systolic bruit → renal artery stenosis, mesenteric ischemia, AAA.
- Friction rubs over liver/spleen → rare but suggest tumour/abscess/inflammation of capsule.

Tip: Succussion splash (rocking patient) audible if gastric outlet obstruction.

3. Percussion

General percussion to map tympany (gas) vs dullness (mass, organ, fluid).
Liver span (midclavicular line): percuss from lung resonance down to liver dullness and from abdomen tympany up — normal ~6–12 cm (adult) — indicates hepatomegaly if increased.
Splenic percussion: Percuss Traube’s space / use Castell’s sign — change from tympany to dullness on inspiration suggests splenomegaly (splenic enlargement = malaria, kala-azar, portal hypertension, haematological disease).
Shifting dullness: test for ascites: percuss center to flank -> mark; patient rolls to side -> dullness shifts = ascites.
Fluid thrill / fluid wave: positive in moderate-large ascites (check with helper).
Percussion for gastric bubble: tympany under left costal margin.

Clinical connections: Increased liver span → hepatomegaly (congestive hepatopathy, hepatitis, fatty liver, malignancy). Fixed dull mass → tumour. Shifting dullness/fluid thrill → ascites.

4. Palpation

Start with light (superficial) then deep palpation in all quadrants. Ask about tenderness early.

Light palpation: detect guarding, superficial masses, tenderness.
- Guarding (voluntary) vs rigidity (involuntary): rigidity = peritonitis (surgical abdomen).
Deep palpation: feel for masses, organomegaly, aortic pulsation. Note size, location, consistency, mobility, tenderness.
Liver palpation: place right hand flat on RUQ, fingers parallel to costal margin, ask patient to take a deep breath. Hooking technique or traditional palpation. Characteristics:
- Smooth, firm, tender → hepatitis, congestive hepatopathy, acute hepatitis (tender).
- Hard, nodular → cirrhosis or tumour.
Spleen palpation: start in right lateral decubitus or supine with patient on right side; palpate from right iliac fossa toward left costal margin during inspiration. Large spleen is palpable below costal margin in splenomegaly.
Kidney palpation: ballottement for renal masses; palpate costovertebral angle for tenderness (pyelonephritis, renal stone).
Aortic pulse: palpate for expansile/pulsatile mass >3 cm in elderly → suspect AAA.
Palpable mass assessment: location, relation to breathing, pulsatility, mobility (respiratory movement suggests organ origin).

Special tenderness tests:

Murphy’s sign: RUQ palpation with inspiration — sudden stop in inspiration = positive → acute cholecystitis.
McBurney’s point tenderness / rebound tenderness → appendicitis / peritonitis.
Rovsing’s sign: left lower quadrant pressure causes right lower quadrant pain → appendicitis.
Psoas sign: pain on passive extension (or active flexion) of right hip → retrocecal appendicitis.
Obturator sign: pain on internal rotation of flexed right hip → pelvic appendix.
Carnett’s sign: increase in pain when patient tenses abdominal muscles (raise head) → abdominal wall source (e.g., rectus sheath hematoma) rather than intra-abdominal.
Heel-jar (Markle) / cough test: pain on heel striking or cough suggests peritonitis (appendicitis/peritonitis).

Interpretation: Localized peritonism → surgical abdomen. Diffuse tenderness + rigidity → generalized peritonitis (urgent).

D. Examination of hernia & inguinoscrotal region

Inspect standing and ask to cough / strain (Valsalva).
Palpate superficial inguinal ring and deep ring; reduce hernia to assess reducibility.
Note scrotal swelling: transillumination, expansile cough impulse, tenderness (strangulation).
Distinguish direct (bulge on cough at Hesselbach’s triangle) vs indirect (through deep inguinal ring) clinically if required.

Why: Hernias can cause obstruction/strangulation — surgical referral if tender and irreducible.

E. Per-rectal (PR) and female pelvic examination (if indicated)

PR exam (on indicated cases; get consent & chaperone):
- Sphincter tone (neuro), palpable masses, tenderness, impacted stool, prostate (in men): size, consistency, nodules (prostate cancer), boggy/tender prostate (prostatitis).
- Check glove for stool color (melena = black/tarry), frank blood.
- Do FOBT (fecal occult blood) if indicated.
Female pelvic exam when pain/bleeding suggests gynae cause — may include speculum and bimanual exam (do with consent/indication).

Connections: PR mass or blood → colorectal cancer, fissure, haemorrhoids, IBD.

F. Quick neurologic/mental check related to GI

Asterixis, confusion → hepatic encephalopathy.
Peripheral neuropathy → malabsorption (e.g., B12 deficiency in celiac disease).

G. Wrap-up tests and bedside adjuncts

Dressing & safety: keep patient warm, allow rest.
Bedside tests you can do: urine dipstick (bilirubin), stool for occult blood, bedside ultrasound (if available) for ascites/hepatosplenomegaly, abdominal X-ray in suspected obstruction/perforation.
Document: location of tenderness, organ measurements (liver span in cm), presence of ascites, type of bowel sounds, positive signs (Murphy, Rovsing, etc.), vital signs.

H. Red flags — immediate action needed

Peritonitis (rigidity, rebound, severe pain) → urgent surgical review.
Hypotension + severe GI bleed (hematemesis/hematochezia) → resuscitate; urgent GI/surgical input.
Signs of sepsis (fever, tachycardia, hypotension) with abdominal source → urgent management.
Suspected obstructed/strangulated hernia → urgent surgery.

I. Practical OSCE / bedside checklist (short)

Consent, chaperone, exposure.
Vitals.
Inspect (patient supine & standing).
Auscultate 4 quadrants + bruits.
Percuss all quadrants + liver & spleen span.
Palpate superficial → deep, check for guarding/rigidity.
Special signs (Murphy, Rovsing, Psoas, Obturator, Carnett).
Hernia exam standing + cough.
PR exam if indicated.
Record findings, provisional differential, red-flag plan.