History and Examination at a Glance

Jonathan Gleadle Oxford Kidney Unit, The Churchill Hospital, Oxford, UK

Preface. List of abbreviations. Part 1 Taking a history. 1 Relationship with patient. 2 History of presenting complaint. 3 Past medical history, drugs and allergies. 4 Family and social history. 5 Functional enquiry. Part 2 History and examination of the systems. 6 Is the patient ill?. 7 Principles of examination. 8 The cardiovascular system. 9 The respiratory system. 10 The gastrointestinal system. 11 The male genitourinary system. 12 Gynaecological history and examination. 13 Breast examination. 14 Obstetric history and examination. 15 The nervous system. 16 The musculoskeletal system. 17 Skin. 18 The visual system. 19 Examination of the ears, nose, mouth, throat, thyroid and neck. 20 Examination of urine. 21 The psychiatric assessment. 22 Examination of the legs. 23 General examination. 24 Presenting a history and examination. Part 3 Presentations. 25 Chest pain. 26 Abdominal pain. 27 Headache. 28 Vomiting, diarrhoea and change in bowel habit. 29 Gastrointestinal haemorrhage. 30 Indigestion and dysphagia. 31 Weight loss. 32 Fatigue. 33 The unconscious patient. 34 The intensive care unit patient. 35 Back pain. 36 Hypertension. 37 Swollen legs. 38 Jaundice. 39 Postoperative fever. 40 Suspected meningitis. 41 Anaemia. 42 Lymphadenopathy. 43 Cough. 44 Confusion. 45 Lump. 46 Breast lump. 47 Palpitations/arrhythmias. 48 Joint problems. 49 Red eye. 50 Dizziness. 51 Breathlessness. 52 Dysuria and haematuria. 53 Attempted suicide. 54 Immunosuppressed patients. 55 Diagnosing death. 56 Shock. 57 Trauma. 58 Alcohol-related problems. 59 Collapse. Part 4 Conditions. Cardiovascular. 60 Myocardial infarction and angina. 61 Hypovolaemia. 62 Heart failure. 63 Mitral stenosis. 64 Mitral regurgitation. 65 Aortic stenosis. 66 Aortic regurgitation. 67 Tricuspid regurgitation. 68 Pulmonary stenosis. 69 Congenital heart disease. 70 Aortic dissection. 71 Aortic aneurysm. 72 Infective endocarditis. 73 Pulmonary embolism and deep vein thrombosis. 74 Prosthetic cardiac valves. 75 Peripheral vascular disease. Endocrine/metabolic. 76 Diabetes mellitus. 77 Hypothyroidism and hyperthyroidism. 78 Addison's disease and Cushing's syndrome. 79 Hypopituitarism. 80 Acromegaly. Nephrology and urology. 81 Renal failure. 82 Polycystic kidney disease. 83 Nephrotic syndrome. 84 Urinary symptoms. 85 Testicular lumps. Gastrointestinal. 86 Chronic liver disease. 87 Inflammatory bowel disease. 88 Splenomegaly/hepatosplenomegaly. 89 Acute abdomen. 90 Pancreatitis. 91 Abdominal mass. 92 Appendicitis. Respiratory. 93 Asthma. 94 Pneumonia. 95 Pleural effusion. 96 Fibrosing alveolitis, bronchiectasis, cystic fibrosis and sarcoidosis. 97 Carcinoma of the lung. 98 Chronic obstructive pulmonary disease. 99 Pneumothorax. 100 Tuberculosis. Neurology. 101 Stroke. 102 Parkinson's disease. 103 Motor neurone disease. 104 Multiple sclerosis. 105 Peripheral neuropathy. 106 Carpal tunnel syndrome. 107 Myotonic dystrophy and muscular dystrophy. 108 Myaesthenia gravis. 109 Cerebellar disorders. 110 Dementia. Musculoskeletal. 111 Rheumatoid arthritis. 112 Osteoarthritis and osteoporosis. 113 Gout and Paget's disease. 114 Ankylosing spondylitis. Other. 115 Systemic lupus erythematosus and vasculitis. 116 Malignant disease. 117 Scleroderma. 118 AIDS and HIV. Appendix: A self-assessment framework of communication skills in history and examination. Index