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History Taking & Clinical Examination - Sémiologie - Semeiotica

NEWS & UPDATES
(Léger Chirurgicale 1999 Sommaire) V1 PDF
(Castaigne Médicale 1992 Sommaire) V2 PDF
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MAPS
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REFERENCES

CONTENTS :
MEDICAL HISTORY - HPI
SIGNS & SYMPTOMS - ROS
PHYSICAL EXAMINATION - PE





GENERAL / IPPA




VITAL SIGNS




SKIN




HEENT
EYE
HEARING
RESPIRATORY
CARDIOVASCULAR



PERIPHERAL VASCULAR


BREASTS & AXILLAE
ABDOMINAL
MALE - RECTAL
FEMALE - PELVIC
UPPER EXTREMITIES
LOWER EXTREMITIES
MUSCULOSKELETAL
NEUROLOGICAL
MENTAL STATUS - MSE
SPORTS
ASSESSMENT & PLAN



MAPS

MEDICINE

TOC
MEDICAL HISTORY

PROCESS

IDENTIFICATION & DEMOGRAPHICS : NAME, AGE, HEIGHT, WEIGHT
CHIEF COMPLAINT - CC

HISTORY OF THE PRESENT ILLNESS - HPI

THE REST OF THE HISTORY

PAST MEDICAL HISTORY - PMH
REVIEW OF SYSTEMS - ROS
FAMILY DISEASES
CHILDHOOD DISEASES
SOCIAL
MEDICATIONS
ALLERGIES
SEXUAL
CONCLUSION & CLOSURE

(NURSING ASSESSMENT
PSYCHIATRIC HISTORY
PROGRESS NOTE
SAMPLE HISTORY
OPQRST
SOAP NOTE
COASTMAP HISTORY)

TOC
REVIEW OF SYSTEMS - SIGNS & SYMPTOMS

CONSTITUTIONAL SYMPTOMS
EYES
EARS, NOSE, MOUTH, AND THROAT (ENT)
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
INTEGUMENTARY/BREAST
NEUROLOGICAL
PSYCHIATRIC
ENDOCRINE
HEMATOLOGIC/LYMPHATIC
ALLERGIC/IMMUNOLOGIC

TOC
PHYSICAL EXAMINATION

TOC
GENERAL / IPPA

TOC
VITAL SIGNS & GENERAL SURVEY

1234
BODY TEMPERATURE BT
HEART RATE OR PULSE HR
RESPIRATORY RATE RR
BLOOD PRESSURE BP


5
PAIN
MENSTRUAL CYCLE
OXYGEN SATURATION
BLOOD GLUCOSE LEVEL

6
END-TIDAL CO2
FUNCTIONAL STATUS
SHORTNESS OF BREATH
GAIT SPEED
DELIRIUM

HEAD-TO-TOE ASSESSMENT: ADULT
HEAD-TO-TOE ASSESSMENT: INFANT
HEAD-TO-TOE ASSESSMENT: CHILD
HEAD-TO-TOE ASSESSMENT: OLDER ADULT

TOC
SKIN

TOC
HEENT - HEAD, EYES, & EARS - NOSE, MOUTH, & NECK

IPPA
I OF SCARS OR SKIN CHANGES
PA OF TEMPOROMANDIBULAR JOINT, THYROID, & LYMPH NODES
PE MAY INVOLVE THE SKIN ABOVE THE FRONTAL SINUSES & PARANASAL SINUSES TO DETECT ANY SIGNS OF PAIN
A FOR CAROTID BRUITS

TESTS SPECIFIC

TOC
EYES : EYE EXAMINATION & ACUITY (INCLUDING OPHTHALMOSCOPE)

EARS : HEARING EXAMINATION & EVALUATION OF TYMPANIC MEMBRANE (TM) (OTOSCOPE USED IN EVALUATION OF EARS, NOSE, & MOUTH)

TOC
THORAX & LUNGS - RESPIRATORY

STAGES
INSPECTION
PALPATION
CHEST PERCUSSION
AUSCULTATION


RESPIRATORY SOUNDS

NORMAL BREATH SOUNDS
ABNORMAL BREATH SOUNDS


TOC
CARDIOVASCULAR SYSTEM

MEASUREMENT OF VITAL SIGNS

CARDIAC EXAMINATION
INSPECTION & PALPATION
PERCUSSION & AUSCULTATION

PULMONARY EXAMINATION
ABDOMINAL EXAMINATION
PERIPHERAL EXAMINATION

HEART SOUNDS
PRIMARY HEART SOUNDS
EXTRA HEART SOUNDS
MURMURS
OTHER ABNORMAL SOUNDS
SURFACE ANATOMY
RECORDING HEART SOUNDS

TOC
PERIPHERAL VASCULAR SYSTEM

POSITION/LIGHTING/DRAPING
INSPECTION
PALPATION
AUSCULTATION
SPECIAL MANEUVERS


TOC
BREASTS & AXILLAE

TOC
ABDOMINAL

PURPOSE

POSITIONING & ENVIRONMENT

INSPECTION

AUSCULTATION

PALPATION

PERCUSSION

OTHER TESTS AND SPECIAL MANEUVERS

TOC
MALE GENITALIA, RECTUM, ANUS, & PROSTATE

TOC
FEMALE GENITALIA, ANUS, & RECTUM - PELVIC

MEDICAL GUIDELINES
PREPARATION, COMMUNICATION, AND TRAUMA-INFORMED CARE
EXTERNAL EXAMINATION
INTERNAL EXAMINATION
DURING PREGNANCY

TOC
UPPER EXTREMITIES

TOC
LOWER EXTREMITIES

TOC
MUSCULOSKELETAL SYSTEM

TOC
NEUROLOGICAL
TOC
NERVOUS SYSTEM: CRANIAL NERVES & MOTOR SYSTEM
TOC
NERVOUS SYSTEM: SENSORY SYSTEM & REFLEXES
TOC
MENTAL STATUS

INDICATIONS

PATIENT'S HISTORY

LIST OF TESTS

MENTAL STATUS EXAMINATION - MSE
The assessment of consciousness, often using the glasgow coma scale (GCS)
Mental status examination, often including the abbreviated mental test score (AMTS) or mini mental state examination (MMSE)
Global assessment of higher functions
Ontracranial pressure is estimated by fundoscopy; this also enables assessment for microvascular disease


CRANIAL NERVE EXAMINATION
(I-XII)
Sense of smell (i), visual fields and acuity (ii), eye movements (iii, iv, vi) and pupils (iii, sympathetic and parasympathetic), sensory function of face (v), strength of facial (vii) and shoulder girdle muscles (xi), hearing (vii, viii), taste (vii, ix, x), pharyngeal movement and reflex (ix, x), tongue movements (xii)
These are tested by their individual purposes (e.g. the visual acuity can be tested by a snellen chart)


MOTOR SYSTEM
MUSCLE STRENGTH, OFTEN GRADED ON THE MRC SCALE 0 TO 5 (I.E., 0 = COMPLETE PARALYSIS TO 5 = NORMAL POWER)
grades 4−, 4 and 4+ maybe used to indicate movement against slight, moderate and strong resistance respectively
MUSCLE TONE & SIGNS OF RIGIDITY
EXAMINATION OF POSTURE
Decerebrate
Decorticate
Hemiparetic
RESTING TREMORS
ABNORMAL MOVEMENTS :
SEIZURE
FASCICULATIONS
TONE
Spasticity
Pronator drift
Rigidity

Cogwheeling (abnormal tone suggestive of Parkinson's disease)
Gegenhalten – is resistance to passive change, where the strength of antagonist muscles increases with increasing examiner force. More common in dementia

DEEP TENDON REFLEXES - DTR
Reflexes: masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar (i.e., babinski sign)
Globally, brisk reflexes suggest an abnormality of the UMN or pyramidal tract,
While decreased reflexes suggest abnormality in the anterior horn, LMN, nerve or motor end plate
A reflex hammer is used for this testing


SENSATION - SENSORY
Sensory system testing involves provoking sensations of fine touch, pain and temperature
Fine touch can be evaluated with a monofilament test, touching various dermatomes with a nylon monofilament to detect any subjective absence of touch perception
LIGHT TOUCH
PAIN
TEMPERATURE
VIBRATION
POSITION SENSE
GRAPHESTHESIA
STEREOGNOSIS, AND
TWO-POINT DISCRIMINATION (FOR DISCRIMINATIVE SENSE)
EXTINCTION
ROMBERG TEST
– 2 out of the following 3 must be intact to maintain balance: i. vision ii. vestibulocochlear system iii. epicritic sensation

CEREBELLUM - CEREBELLAR TESTING
DYSMETRIA
Finger-to-nose test
Ankle-over-tibia test
DYSDIADOCHOKINESIS
Rapid pronation-supination
ATAXIA
Assessment of gait
NYSTAGMUS
INTENTION TREMOR
STACCATO SPEECH

INTERPRETATION


TOC
COMMUNICATION & INTERPERSONAL SKILLS

TECHNIQUE: ACTIVE OR ATTENTIVE LISTENING
TECHNIQUE: GUIDED QUESTIONING
TECHNIQUE: EMPATHIC RESPONSES
TECHNIQUE: SUMMARIZATION
TECHNIQUE: TRANSITIONS
TECHNIQUE: EMPOWERING THE PATIENT
TECHNIQUE: REASSURANCE
USE OF UNDERSTANDABLE LANGUAGE
USE OF NON-STIGMATIZING LANGUAGE
APPROPRIATE NONVERBAL COMMUNICATION
USE OF PREFERRED TITLE, NAME, AND GENDER PRONOUN
INTERPROFESSIONAL COMMUNICATION
PATIENT-CENTEREDNESS IN COMPUTERIZED CLINICAL SETTINGS
TEACH-BACK METHOD
RAPPORT: NEWBORNS AND INFANTS
RAPPORT: YOUNG CHILDREN
RAPPORT: ADOLESCENTS
RAPPORT: OLDER ADULTS
RAPPORT: PATIENTS WITH PHYSICAL AND SENSORY DISABILITIES
REPORT: LGBTQ+ ADULTS
BROACHING SENSATIVE TOPICS
OBTAINING INFORMED CONSENT
DISCUSSING ADVANCE DIRECTIVES
WORKING WITH MEDICAL INTERPRETERS
DISCLOSING SERIOUS NEWS
RESPONDING TO EMOTIONAL CUES
MOTIVATIONAL INTERVIEWING


TOC
OSCE - CLINICAL SKILLS

OSCE 1: CHEST PAIN
OSCE 2: ABDOMINAL PAIN
OSCE 3: SORE THROAT
OSCE 4: KNEE PAIN
OSCE 5: COUGH
OSCE 6: VOMIT
OSCE 7: AMENORRHEA
OSCE 8: FALLS
OSCE 9: BACK PAIN
OSCE 10: SHORTNESS OF BREATH
OSCE 11: SHOULDER PAIN
OSCE 12: CHILD AND ADOLESCENT ASTHMA
OSCE 13: HEADACHE
OSCE 14: CHILD AND ADOLESCENT OBESITY
OSCE 15: MEMORY LOSS


DATA INTERPRETATION

PRESENTATIONS

EMERGENCY

SURGERY
General surgery
Vascular
Urology
Musculoskeletal


ABG, cannulation, IVI, IV Abx   
Abdominal examination   
Antenatal clinic   
Blood transfusion   
Breaking bad news diabetes   
Breaking bad news ectopic   
Breaking bad news misscariage   
Breaking bad news multiple sclerosis   
Cardiac arrest AED   
Cardiac arrest manual   
Cardiovascular examination   
Catheterisation   
Chest Xray           
Counselling contraception   
Counselling CABG   
Counselling hernia repair   
Counselling cholecystectomy   
Counselling TURP   
Digital rectal examination   
Endocrinology   
Gynae examination   
Hand examination   
Hernia   
Lower limb vascular examination   
Mental state examination   
Nasogastric tube   
Neurology cranial nerves   
Neurology examination   
Orthopaedic examination   
Parkinsons disease   
Respiratory examination   
Sexual history taking   
Stoma, AV fistua, CAPD  


SPECIALITIES

REFERENCES

CONTENTS :

OVERVIEW REVIEW DIDACTIC




OVERVIEW & REVIEW
MediMaps. Summary [ PDF - PPT ]
Gleadle. History & Clinical Examination At a Glance. 3e. 2012. [ Download ]
Blundell. OCSEs At a Glance. 2e. 2013.
medimaps.co.uk/osce - web.archive.org/web/*/http://medimaps.co.uk/osce
Castaigne. Sémiologie Médicale. Initiation ŕ la Physiopathologie. 1992. [ Download ] [ Download ]
Goldberg. Practical Guide to Clinical Medicine. 2018. [ Link ]

DIDACTIC
Bickley. Bates' Guide to Physical Examination and History Taking. 13e. 2020. [ 1072 pages ] [ Download 13e ] 
Bates' Visual Guide to Physical Examination. [ batesvisualguide.com ]
Bates’ Pocket Guide to Physical Examination and History Taking. 8e. 2016.

WIKIPEDIA
https://en.wikipedia.org/wiki/Template:Medical_records_and_physical_exam
https://en.wikipedia.org/wiki/Template:Orthopedic_examination
https://en.wikipedia.org/wiki/Signs_and_symptoms

VIDEOS
HippocraTV. Clinical Examination for Beginners. [ Playlist ]
https://medicalstudyzone.com/macleods-clinical-examination-hd-videos-free-download/

https://medquestreviews.com/store/get-physical-video-series
https://medicalstudyzone.com/medquest-get-physical-videos-download/
https://mega.nz/folder/5JAxSSTa#0DvfUW2fKXvcryHNpHz71w

https://www.youtube.com/@medquestreviews6854/featured

CARDIOVASCULAR
Dr Ho's Murmurs
https://www.youtube.com/watch?v=jq7-mmkirNM
https://www.practicalclinicalskills.com/heart-sounds-murmurs

NEUROLOGY
Cranial Nerve Examination - OSCE Guide (New Version) https://www.youtube.com/watch?v=sJBpai74tlU
https://web.archive.org/web/20190307173749/https://huibee.com/wordpress/wp-content/uploads/2013/11/Mental-State-Exam-form.pdf

PAEDIATRICS / NEONATES
Normal Physical Exam on an Infant [ View ] [ Download ]

SURGERY
Léger. Sémiologie Chirurgicale. 6e. 1999. [ Download ]
Burnand. Browse's Introduction to the Symptoms & Signs of Surgical Disease. 6e. 2021.
[ Download 4e ] [ Download 5e ] [ Amazon ]

MORE REFERENCES

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