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History Taking & Clinical Examination - Sémiologie - Semeiotica
SIMPLE CONTENTS
NEWS & UPDATES
MAPS
OVERVIEW
REFERENCES
FRANÇAIS
ITALIANO
TOC
DETAILED CONTENTS
NEWS & UPDATES
MAPS
OVERVIEW
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
REFERENCES
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MAPS
TOC
OVERVIEW
(Léger Chirurgicale 1999 Sommaire) V1 PDF
(Castaigne Médicale 1992 Sommaire) V2 PDF
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MEDICINE
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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)
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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
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PHYSICAL EXAMINATION
TOC
GENERAL / IPPA
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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
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SKIN
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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
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EYES : EYE EXAMINATION & ACUITY (INCLUDING OPHTHALMOSCOPE)
EARS : HEARING EXAMINATION & EVALUATION OF TYMPANIC MEMBRANE (TM) (OTOSCOPE USED IN EVALUATION OF EARS, NOSE, & MOUTH)
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THORAX & LUNGS - RESPIRATORY
STAGES
INSPECTION
PALPATION
CHEST PERCUSSION
AUSCULTATION
RESPIRATORY SOUNDS
NORMAL BREATH SOUNDS
ABNORMAL BREATH SOUNDS
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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
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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
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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
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UPPER EXTREMITIES
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LOWER EXTREMITIES
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MUSCULOSKELETAL SYSTEM
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NEUROLOGICAL
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NERVOUS SYSTEM: CRANIAL NERVES & MOTOR SYSTEM
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NERVOUS SYSTEM: SENSORY SYSTEM & REFLEXES
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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
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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
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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
DIDACTIC
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
Goldberg. Practical Guide to Clinical Medicine. 2018. [ Link ]
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.
Castaigne. Sémiologie Médicale. Initiation à la Physiopathologie. 1992. [ Download ] [ Download ]
Léger. Sémiologie Chirurgicale. 6e. 1999.
[ Download ]
https://www.unitheque.com/Blog/quels-livres-semiologie-choisir/7166
OVERVIEW
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
https://learn.practicalclinicalskills.com/
https://meded.ucsd.edu/clinicalmed/introduction.html
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
https://depts.washington.edu/physdx/heart/demo.html
RESPIRATORY
https://www.youtube.com/watch?v=2NvBk61ngDY
https://www.youtube.com/watch?v=bHGlFmd4Fuk&list=PLxsQDK_5AH20Ks2X3a0CKkY7MiVVjXqj1&index=4
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
https://neurologicexam.med.utah.edu/adult/html/home_exam.html
PAEDIATRICS / NEONATES
Normal Physical Exam on an Infant [ View ] [ Download ]
SURGERY
Burnand. Browse's Introduction to the Symptoms & Signs of Surgical Disease. 6e. 2021. [ Download 4e ] [ Download 5e ] [ Amazon ]
https://teachmesurgery.com/examinations/
https://medicina08.univpm.it/index.php?option=com_jdownloads&view=category&catid=536&Itemid=1218
https://www.ncbi.nlm.nih.gov/books/NBK201/
MORE REFERENCES
Wayback Machine
NEWS & UPDATES