مجموعة Check list for history taking exam

Good luck 🤍

السلام عليكم دكاترة ✨️

كيف حالكم و ان شاء الله أموركم تمام مع إمتحان الاورال

حنبدا معاكم من اليوم تجهيزاً لإمتحان الكلينك💪

حنزللكم خطوات ال examination لكل سيستم زي ما يبوه في الإمتحان و معاه امتلة

يعني شن ممكن يجي في كل لجنة و كيف تعطوا presentation و شنو الأسئلة اللي تنسأل 📝

بالتوفيق 🤍

🟪CVS examination

Initial approuch to the patient, introduce yourself, explain what are you going to do , take permission , ask about pain , hand hygiene

➡️Inspection
Inspect the chest for deformity, scars , visible pulsation, visible dilated veins , any skin lesions (bruises , cautery marks)

➡️Palpation
Palpate the apex beat and describe its character then localise its site
Palpate for Lt parasternal heave
Palpate for trill

➡️Auscultation
Auscultate mitral area by diaphragm of stethoscope for S1 + Murmer of MR
Auscultate axilla for radiation of MR
Auscultate mitral area by bell of stethoscope while you're turning the patient to his lt lateral side
Auscultate tricuspid area by diaphragm of stethoscope for murmur of TR / TS
Auscultate 1st aortic area for S2 + Murmer of AS
Auscultate the root of neck for radiation of AS
Auscultate pulmonary area for murmur of
PR/PS
Auscultate 2nd aortic area for murmur of AR then leaning the patient forward and ask him to hold breathing on expiration

Describe your findings
Give appropriate DD
Elict investigations which will help you to reach you Dx
Overall approach to task
Total mark

🟨Case 1

By inspection
The chest is symmetrical , the is a midsternotomy scar , no chest deformity , no visible pulsations , no bruises all over the chest

By palpation
The apex beat is palpable which is  gentle non sustained and localised at 6th ICS AAL
(ملاحظة :-اغلب اللي مدايرين open heart تلقوا ال apex beat مش في مكانها )

There is no lt parasternal heave
There is no trill all over the chest

By auscultation
First heart sound is audible
Second heart sound is metallic in nature
No murmurs
No added sounds

◾️DX
Aortic Valve replacement

■What are the complications of prostetheic Valve replacement?
➡️Early complications
Thrombosis
➡️late complications
Dysfunction (AR> AS)
IE
Hemolytic anemia

◾️How to follow up this patient
Echo
INR

🟨Case 2

By inspection
The chest is symmetrical , the is a midsternotomy scar , no chest deformity , no visible pulsations , no bruises all over the chest

By palpation
The apex beat is palpable which is  gentle non sustained and localised at 5th ICS MCL

There is no lt parasternal heave
There is no trill allover the chest

By auscultation
First heart sound is metallic in nature
Second heart sound is audible
No murmurs
No added sounds

◾️DX
Mirtral Valve replacement

■What are the complications of prostetheic Valve replacement?
➡️Early complications
Thrombosis
➡️late complications
Dysfunction (MR> MS)
IE
Hemolytic anemia

◾️How to follow up this patient
Echo
INR

🟨Case 3

By inspection
The chest is symmetrical , there is a midsternotomy scar , no chest deformity , no visible pulsation , no bruises all over the chest

By palpation
The apex beat is palpable which is  gentle non sustained and localised at 6th ICS AAL
(ملاحظة :-اغلب اللي مدايرين open heart تلقوا ال apex beat مش في مكانها )

There is no lt parasternal heave
There is no trill allover the chest

By auscultation
First heart sound is metallic in nature
Second heart sound is metallic in nature
No murmurs
No added sounds

◾️DX
Bivalve replacement (AVR and MVR)

■What are the complications of prostetheic Valve replacement?
➡️Early complications
Thrombosis
➡️late complications
Dysfunction (AR> AS)
IE
Hemolytic anemia

◾️How to follow up this patient
Echo
INR

🟨Case 4

By inspection
The chest is symmetrical , no chest deformity , no visible pulsation ,no scars , no bruises all over the chest

By palpation
The apex beat is palpable which is  gentle non sustained and localised at 6th ICS AAL
There is a lt parasternal heave
There is a trill over the mitral area

By auscultation
First heart sound is muffled
Second heart sound is audible
There is a pansystolic murmur at mitral area radiats to the axilla, probably grade 4
No added sounds

◾️DX
MR

■What are the causes of MR ?
1_Myxomatous degeneration
2_MVP
3_Post MI
4_ IE and rheumatic fever
5_ Collage vascular disorder/ marfan syndrome, ehler danlos syndrome

◼️Elict investigations which will help you to reach your Dx
Echo
CXR
ECG

🟨Case 5

By inspection
The chest is symmetrical , no chest deformity , there is a visible pulsation over the mitral area ,no scars , no bruises all over the chest

By palpation
The apex beat is palpable which is forceful and localised at 5th ICS AAL
There is no lt parasternal heave
There is a trill over 1st aortic area

By auscultation
First heart sound is audible
Second heart sound is muffled
There is an ejection systolic murmur at 1st aortic area radiats to the root of neck, probably grade 4
No added sounds

◾️DX
AS

■What are the causes of MR ?
1_Degenerative calcification
2_ Congenial bicuspid aortic Valve
3_Post rheumatic disease
4_ HOCM


◾️Elict investigations which help you to reach your Dx
Echo
CXR
ECG

🟪Abdominal examination

Initial approuch to the patient, introduce yourself, explain what are you going to do , take permission , ask about pain , hand hygiene

➡️Inspection
Inspect for abdominal symmetry, abdominal distension , ask the
patient to take breath and Inspect for abdominal movement , Inspect the umbilicus and ask the patient to cough , Inspect for scars, superficial dilated veins , brucies, skin pigmentation,stia ,scratch marks

➡️Palpation
◾️Superficial palpation
Ask the patient if he has pain then palpate the whole 9 abdominal areas for Superficial masses, tenderness and hotness
◾️Deep palpation
Palpate the live and measure the liver span
Palpation the spleen
Do balotabale test

➡️Percusdion
Test for Stiffening dulness (if +ve then test for fluid trill)

➡️Auscultation
Ascultate over macbarny point for bowel sounds
Ascultate 1 cm above and lateral to the umbilicus for bruit
Ascultate Rt hypochondrial area for hump and bruit (if patient has signs of portal hypertension)
Auscultate Lt hypochondrial area for fraction rub (if patient has splenomegally)

Describe your findings
Give appropriate DD
Elict investigations which will help you to reach you Dx
Overall approach to task
Total mark

🟨Case 1

A middle aged man looks pallor ecteric , his abdominal examination reveled

By inspection
Distended abdomen with full flanks and multiple stria over the abdomen , moves with respiration , there is an paraumbilicual herina with +ve cough impulse , No scar , No bruises , No scratch marks, No superficial dilated veins

By palpitation
Abdomen is soft lax , No tenderness No hottness all over the abdominal areas , I can't detect any superficial masses
The liver is not Palpable and the liver span is  6 cm (shrunken liver)
Spleen is palpable 4 cm below costal margin , not tender , hard in consistency with smooth surface and its dull on Percussion
-ve Ballotable test

By Percussion
+ve shifting dullness, +ve trill test

By Ausculation
Bowel sounds is ..../min
No bruit No hump over the Rt hypochondrial area .

◾️Most likely Dx
Liver cirrhosis

◾️What are the causes of liver cirrhosis

◾️Elict investigations which will help you to reach your Dx

LFT
U/E/Cr
Diagnostic paracentesis
Abdominal US
Upper git endoscopy
Inv for the cause / viral screen ,ect

🟨Case 2

A middle aged make looks pale and ecteric, his abdominal examination reveled

By inspection
Distended abdomen with full flanks and multiple stria over both lower abdominal quadrants , moves with respiration , umbilicus is inverted , _ve cough impulse , No scar , No bruises , No scratch marks, No superficial dilated veins

By palpitation
Abdomen is soft lax , No tenderness No hottness all over the abdominal areas , I can't detect any superficial masses
Liver is palpable approximately 4 cm below the coastal margin , not tender with smooth surface ,firm in consistency and liver span is 15 cm(enlarged)
Spleen is not palpable
-ve Ballotable test

By Percussion
+ve shifting dullness, +ve trill test

By Ausculation
Bowel sounds is ..../min
No bruit No hump over the Rt hypochondrial area .

◾️DD
1_CHF
2_budd chiari syndrome
3_early liver cirrhosis (Alcoholic hepatitis ,hemochromatosis , Wilson)
4_hepatocellular carcinoma

◾️Investigations
Echo
Abdominal US
CBC
LFT
U/E/Cr
Diagnostic paracentesis ...


الحالة كان تشخيصيه Wilsone.

🟨Case 3

An old aged male looks unwell dysnic, his abdominal examination reveled

By inspection
Distended abdomen with full flanks , moves with respiration , umbilicus is inverted , _ve cough impulse , No scars , No bruises , No scratch marks, No superficial dilated veins

By palpitation
Abdomen is soft lax , No tenderness No hottness all over the abdominal areas , I can't detect any superficial masses
Liver is not palpable with liver span = 8 cm
Spleen is not palpable
-ve Ballotable test

By Percussion
+ve shifting dullness, -ve trill test

By Ausculation
Bowel sounds is ..../min
No bruit No hump over the Rt hypochondrial area .

◾️DD
🔸️Transudative
1_ CHF
2_ Liver cirrhosis
3_ Nephrotic syndrome
4_ Hypothyroidism

🔸️Exudative
1_ Infection
2_ Malignancies

◾️investigations
Abdominal US
Diagnostic paracentesis
Serum  ascitis albumin gradient
لو طلع High gradient نبعت👇

CBC
FBS
LFT ( AST , ALT , bilirubin , Albumin, PT , PTT (
U/Cr/E
ABG
Upper git endoscopy
Fibroscan
Liver biopsy مش مهمة و ما يدروش فيها
(طبعاً هادو على خاطر ال liver cirrhosis )

ECG
ECHO
CXR
(على خاطر لو كان السببCHF )

لو طلعت low gradient 👇
Urine for RE
RFT
24 hr urine collection
(على خاطر nephrotic syndrome )

🟨Case 4

A young male looks ill pallor , his abdominal examination reveled the following

By inspection
The abdomen is not distended , moves with respiration with inverted umbilicus and -ve cough impulse , No scar , No bruises , No any skin abnormalities

By palpitation
Abdomen is soft lax , No tenderness No hottness all over the abdominal areas , I can't detect any superficial masses
The liver is Palpable 4 cm below costal margin , not tender , hard in consistency with smooth surface and the liver span is  16 cm (enlarged liver)
The spleen is palpable 3 cm below costal margin , not tender , hard in consistency with smooth surface and it was dull on Percussion
-ve Ballotable test

By Percussion
-ve shifting dullness

By Ausculation
Bowel sounds is ..../min
No bruit No hump over the Rt hypochondrial area .
No fraction rub over Lt hypochondrial area

◾️DD
1_Extra medullary hematopoiesis / Hemolytic anemia
2_Malignanicies / Leukemia, lymphoma
3_Congested liver and spleen (CHF , Budd chiari syndrome
4_ Infection / EPV , CMV , HIV
5_Autoimmune diseases / SLE

◾️Investigations
➡️investigations for hematological causes
CBC
Blood film
Bone marrow biopsy
LDH
Heptoglobulin
Bilirubin
و لما التحاليل هادي تاكدلي انها فعلاً hemolytic
نبعت تحاليل باش نعرف السبب👇

ESR CRP ANA Antids...(على خاطر ال acquired causes /  eg :- SlE  )

و بالنسبة لل congenital causes هوني كل نوع عنده تحليل خاص بيه تقوله .
Osmotic fragility test
G6P level
Hemoglobin electrophoresis

➡️ investigations for Cardiac causes
Echocardiography

➡️Investigations for Infection
Serolgy
Viral screen

➡️investigations for autoimmune diseases
ESR
ANA
Antids DNA

Also l have to do
LFT
US abdomen

🟪Chest examination from the back

Initial approuch to the patient, introduce yourself, explain what are you going to do , take permission , ask about pain , hand hygiene

➡️Inspection
Inspec the chest for any deformity , scars (lateral thoracotomy scar , scar of plural tap) , any skin lesion (cautery marks)
Ask the patient to take a breath and look for his chest movement

➡️Palpation
chest expansion
TVF

➡️Percussion
➡️Auscultation
Auscultate the chest for air enty , type of breathing, added sounds
Auscultation the chest for vocal resonance

Describe your findings
Give appropriate DD
Elict investigations which will help you to reach you Dx
Overall approach to task
Total mark

#Respiratory
اكثر فايندينق تجي
🔸️Rhonchi
~و يسالك بعدها على ال DD ؟
1_Asthma
2_COPD
3_Pneumonia
...ect
~بعدها يسألك على ال investigations ؟
طبعاً زي ما محفظنا سيف
ABG ,pusle oxymetry
CXR
PFT
و تزيد عليهم👇
Spirometry , peak flow meter
(على خاطر الازما )
HRCT
(على خاطر لو عنده امفيزيما )
CBC
Sputum culture, blood culture, urine culture
(على خاطر النيومونيا )
المهم الخلاصة بتسمي الانفزتيقيشن على حسب ال DD
..........................................................................
🔸️Fine crepitation
~يسألك بعدها عال DD
1_ILD
2_early pneumonia
3_pulmonary edema as complications of HF
~ و يسألك بعدها عال investigations ؟
نفس الشي
ABG
PFT
CXR
و تزيد عليهم 👇
CBC
ESR , CRP
CTD screening / ANA , Antids
HRCT
BAl
Biopsy
( على خاطر ال ILD )
Echo
(على خاطر pulmonary edema )
Sputum culture , blood culture
(على خاطر النيومونيا )
...........................................................................
🔸️Course crepitation
~يسألك بعدها عال DD ؟
1_Bronchiactasis
2_chronic bronchitis
3_late pneumonia
~ و يسألك بعدها عال investigations ؟
نفس الشي
ABG , pusle oxymetry
PFT
CXR
و تزيد عليهم 👇
HRCT
Sputum microbiology
Serology
Sacharin test
Ig level
(على خاطر ال Bronchiactasis )
CBC
Sputum culture, blood culture
(على خاطر ال نيومونيا )

حاجة تانية في الريسبيراتوري ، مرات الفياندينق تكون👇
Decreased air entry
Dullness at lower zones
Chest tube under water seal
~يسألك بعدها على ال DD of dulness ؟
1_Pleural effusion
2_Collapse
3_Consolidation
~و يسألك بعدها على ال most likely Diagnosis و اللي هو plural effusion.
~و يسألك على ال causes ؟
➡️A_General
CHF
Nephrotic syndrome
Liver cell failure
➡️B_local
Pneumonia
TB
CTD / SLE , RA
Malignancies
Pulmonary infarction
~بعدها يسألك على ال investigations ؟
CXR
CT scan
US مرات تفيدني بس
ABG , pulse oxymetry
Plurocentesis /باش نحدد النوع exudative او transudative

و على أساس التحليل هذا بنبعت تحاليل تانية باش نزبط ال cause ؟
لو كان transudative
بنبعت
ECG
Echo
Urine for RE
U/Cr/E
LFT
Abdominal US
لو كان السبب exudative
نفس الشي بتبعت تحاليل باش تستبعد كل الاسباب
CBC
Sputum culture, blood culture
Quantiferon test
ESR , CRP
ANA , Anti ds

🟪General examination

Initial approuch to the patient, introduce yourself, explain what are you going to do , take permission , ask about pain , hand hygiene

➡️General look
A / appearance
B / bulit
C / conscious level
S / skin (clour , rash , brucies , scar , pigmentation , fistula )
S / surroundings (cannula , O2 mask , medications )

➡️ head
1_Hair /for hair distribution
2_Eyes / for sings of anemia and jundice
3_Face / malar rash
4_Mouth / for sings of anemia (Angular stomatitis + pale mucous membrane , smooth tongue) , central cyanosis , mouth hygiene, artificial teeth.

➡️neck
1_Look for any Neck swelling
2_Palpate the Trachea/ centalized or deviated
3_Palpate Carotid artery and look for JVP
4_LN examination

➡️ hands
1_Inspect dorsal surface
2_Inspect palmer surface / for pale palmer creases , palmer erythema , atrophy of thenar and hypothenar ms
3_Inspect nails / for leukonykia, kolionykia , peripheral cyanosis , culbbing
طبعا لازم اديروا test for clubbing
inspect the nail angle
Fluctuation test
Window sing
4_Test for fine and flapping tremors
5_VS measurement

➡️ LL
1_Inspect for symmetry, sewlling and for any skin changes
2_Palpate for hotness and tenderness
3_Test for BLLE
4_Inspect between toes for fungal infection
5_Palpable dorsalis pedis artery and posterior tibilal artery


Describe your findings
Give appropriate DD
Elict investigations which will help you to reach you Dx
Overall approach to task
Total mark

#General
لو كانت الفايندينق jaundice

~يسألك بعدها عال DD of jaundice ؟

A_per_hepatic / Hemolysis
B_Hepatic / hepatitis , liver cirrhosis and its cases , malignancies
C_pos_thepatic / Stone , PBC , PSC , Cancer head of pancreas

~بعدها يسالك على ال investigations ؟
🔸️per_hepatic
CBC
Blood film
LDH
Heptoglobulin
Bilirubin
ESR , ANA , Anti ds
( على خاطر ال acquired causes of hemolytic anemia )

و باقي التحاليل اللي خاصة بكل نوع من ال congenital causes
HB electrophoresis
Osmotic fragility test
G6P level

🔸️Hepatic , post_hepatic
LFT
Abdominal US
MRCP
ERCP