Preface
AIMST UNIVERSITY
KEDAH
MALAYSIA
FACULTY OF MEDICINE
UNIT OF MEDICINE
LOG-BOOK
NAME
_______________________________________
MAT NUMBER_______________________________________
BATCH
______________ GROUP _________________
POSTING FROM______________ TO _____________________
YEAR III/ IV /V
NOTE
STUDENTS MUST HAVE THE LOG BOOK WITH THEM DURING WARD ROUNDS /
CLINICAL SESSIONS.
STUDENTS MUST OBTAIN SIGNATURES FROM THEIR SUPERVISING
CONSULTANT / DOCTOR ON A DAILY BASIS
Index
Sl NoPage no.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
DECLARATION
IMat No:, hereby declare that this logbook is a record of all
clinical cases that I have clerked in and the clinical activities
that I have been a part of , at Hospital
during my year III / IV / V clinical posting in the unit of
....Medicine..............................
from . to..Signature
Name:
Mat No:
CERTIFICATE
Certified that this log book is a bonafide record of all
clinical activities by
Mr. /Ms., Mat No.........................................
during his/her year III / IV / V clinical posting in the unit of
..........................................
at Hospital
Head of Unit Head of Department
Unit of Medicine Department of Medicine
AIMST UNIVERSITY Hospital
Date: Date:
Sl noDateName of consultantActivitySignature
Preface
This Log book will be a record of the clinical training and
experience that you shall obtain during your junior clerkship. It
contains notes on scheme for history taking and physical
examination that is aimed at sharpening your skills in performing
clinical work. The junior clerkship is an important first phase of
your active clinical posting and builds on the walk-through that
you had it in the seven weeks exposure you had it in the hospital
environment during your second year. You are urged advised to read
up various recommended textbooks on clinical methods during the
course.
During the twelve week of posting this year, you are expected to
present at least six long cases jointly with one of your
colleagues. All the six cases should be recorded in this log book
and be subjected to evaluation by clinical teacher. A total number
of fifteen cases during junior clerkship and Ten cases during
Senior Clerkship should be recorded by each of you. In addition to
the clinical cases record must be made of all the P B L sessions
that are conducted during the posting.
The cases that you will be exposed to shall cover a range of
general medical problems that will provide ample opportunity to
develop your communication skill and to learn and appreciate
Clinical history taking and Physical examination. Accurate record
of the history and examination of each case that you are involved
in should be made in this log book in as much as they will form a
part of your continuous assessment.
Introduction to Clinical Examination
The sole purpose of medical practice is to relieve suffering due
to disease, which makes diagnosis mandatory. In order to achieve
this, one needs to develop a friendly and sensitive approach to
patients so as to understand them with regard to their social and
family history. It is important not only to elucidate the problems
posed by disease but also apply their clinical skills to advice
patients and families how to manage these problems which is
achieved by constant practice of the skills by combination of study
and experience. Appropriate skills are needed to elicit the
symptoms from the patient's description and conversation and the
signs by observation and by physical examination. It is also
important to respect patients rights For example, if a patient
indicates that he or she does not wish to discuss certain topics,
or to be examined fully, this wish must be respected. Remember
always that the communication is a two way process. To arrive at a
proper diagnosis it is necessary to establish the clinical features
by clinical history and examination. This forms the clinical
database, and interpretation of the database leads to
diagnosis.
It will be comfortable for the patient if the clinician himself
brings into the clinic with offer of greeting. The response of the
patient to questioning will in cases reveal the clinical condition.
Another aspect is the surroundings in the office, which should be
pleasant and patient friendly. It is important that the doctor pays
full attention while the patient presents himself. It is also good
to exchange pleasantries with accompanying persons. This will
provide some more information about the social background,
education level, etc., of the patient himself. After the initial
informal preliminaries, the doctor can proceed to presenting
clinical problem. It is better to maintain a slight sense of
formality and neutrality in the relationship but make it clear that
you want to hear what the patient has to say and you will inspire
confidence by this. It is a good to get at least some information
on personal, marital status, employment, basic family & social
and medical history including allergies etc., these details will
help the doctor to discuss symptoms and problems. Getting
Started:
As conversational skills are central to proper history it is
important to remain flexible and to be prepared to change your
approach if it seems that a new start is needed. Encourage patients
either to start from the beginning, or to describe the particular
problem that worries them the most. Expecting patients to be open,
you must make it clear that you will also be open with them. If you
feel there is a cloud developing in your relationship with a
particular patient, try gently to find out why and clear it.
OBSERVE YOUR PATIENT
The communication process is to enable you to make assessment of
patient's general demeanour.
Personality and Presentation.
Sign of disability, physical or mental?
What clues does the gesture convey?
The general approach and psychological feelings.
Is he or she expressing all the facts or withholding certain
things.
the gait.
the voice (whether normal or hoarse).
Make it clear to your patients that you expect them to speak
freely and give their own account of the problem. Avoid suggesting
symptoms until the patient has finished this description, when you
may wish to obtain more detail or to enquire specifically about
certain symptoms not so far mentioned. If there are points that are
not fully described, or which you think are important, do not be
afraid to ask directly for more information. However, recognize
that this will interrupt the patient's flow of recall, and that you
will then need to restart the spontaneous description that you
interrupted.
While making notes, try to keep eye contact with the patient.
Listen to the patients complaints; make up your mind of what is
being said and record enough to help you remember the important
points. Later, you can write up a fuller account of the history and
pertinent points based on the weight placed on various items and,
most importantly, what the patient actually said. What patients
say, word for word, is often as important as any later
reconstruction of the history.
Direct but relevant questions form an essential component of
historytaking. It is rather ideal to bring up those direct
questions once the patient has completed expressing the complaints.
If you are not sure of something or noticed any abnormality, ask
for more details directly. These can again be brought in more
detail while examining the patient. After a clear understanding of
the case and presentation, it is always good to start examining
symptom wise starting from the primary complaint.
Try and relate the history from the preliminary information you
have obtained as regards to the patient's occupation, past medical
history and family history to the symptoms.
Use common and colloquial words that patient can understand. Use
words like passing urine, motion etc., rather than using medical
terminology.
Another important but difficult to establish, is the functional
disorders which needs careful and detailed interrogation.
Exaggeration of symptoms may pose problem while interrogating
the patient though the symptom may be true. This has to be
sympathetically approached but firm in approach so as to analyse
the depth of the symptom. It is important to establish good and
reasonable relationship with the patients, which might not be easy
in some Difficult and angered patients, which might be because of
distress or disbelief. Adopt a soothing attitude and keep
reassuring the patient.
Some time during integration the patient may introduce unrelated
information without context but could be a clue to the underlying
disease state.
Information obtained from a concerned and observant relative is
often helpful.
ANALYSIS
The main objective of the history is to analyse the disturbance
of function and structure responsible for the patient's symptoms.
Symptoms always have a physiological or anatomical basis. Certain
physiological symptoms have to be properly analysed or will lead to
erroneous diagnosis. The most common examples are thirst, passing
of large quantities of urine etc; which should be correlated with
other symptoms. Even if there are any negative data it should also
be analysed.
PAIN is one of the commonest complaints which bring the patient
to the doctor. Systematic analysis of this symptom is important and
a standard approach is essential for the evaluation of the
same.
Simple questions like Where is the pain? What is the nature of
pain? How is the pain relieved?, will be helpful assessing pain.
The other leading questions with regard to radiation of pain,
severity, timing and duration and character, occurrence or
aggravation and relief will be useful in proper understanding of
the symptom. PAST HISTORY
It is important to go through the past history in light of the
current illness. But make sure that the patient's description of
the diagnosis of an earlier illness is consistent and likely to be
correct check on the treatment he or she had and possibly try
checking the information from the earlier physician or hospital.
Check on the medication including the non prescribed and non
proprietary drugs and also about alternative or herbal remediessome
of the latter can be powerful and may produce serious unwanted
effects such as renal failure. You should also considering asking
about sexual habits and drug abuse if deemed necessary. It is
equally important to know whether is patient had any allergies for
drugs or otherwise.
SPECIAL QUESTIONS FOR WOMEN
Certain information regarding the menstrual and obstetric and
gynaecological history is important and essential. Others should
include intake of oral contraceptives or other hormones etc.,
OCCUPATIONAL HISTORY
Another important aspect of history taking is regarding the
patients occupation and exposure to toxic and industrial
pollutants.
GENETIC HISTORY
The genetic history has become necessary because of role of
genetic factors in many diseases. They could be inherited with
dominant or recessive or sex linked. Mitochondrial inheritance in
certain brain and muscle disease is also well understood. Inherited
disorders are generally more common in populations in which first
cousin marriages are common, as happens in isolated communities,
and among certain religious groups, especially in some Muslim
communities. Diabetes and Coronary Artery Disease especially
lipoproteineamias show inherited factors in their causation.
THE PHYSICAL EXAMINATION
After going through the exercise of history taking, record all
the salient and important features. After having completed the
history taking, the doctor should proceed to the physical
examination: the routine combined with specific, relevant to that
patient. The examination should be thorough but without much
discomfort to the patient. The depth of examination should be
decided based on the severity of the condition. Start the
examination in a manner that is relevant to the patient's symptoms
but develop a systematic approach to each functional system in
order to gain information that is both complete and relevant.
GENERAL APPROACH
The examination room should be well lit, warm and exclusive
ambience. Make the patient comfortable.
First inspect the physique and expression, to rule out any
obvious physical disability / skeletal disorders / obesity/ wasting
/ malnutrition etc., Information regarding the patient's health can
be gained looking at the face. Nephrotic Syndromes, Congestive
Cardiac Failure, Anaemia are some examples.
The next is to look at the skin for examination of pallor,
colour, pigmentation, cyanosis (Central and Peripheral) and
cutaneous eruptions etc.,
The skin is dry and inelastic in dehydration - the skin can
easily pinched up.
Pallor is a sign of anaemia and best observed in conjunctiva.
Cyanosis is best observed in finger nails.
The next is to observe for the presence of oedema. Oedema of
face is characteristic of early phase of acute nephritis, which is
most marked when the patient rises in the morning.
Dependent oedema, which is typically around the ankle and dorsum
of foot, is present in Congestive Cardiac Failure, and in
conditions associated with a low plasma protein level such as
malnourishment etc., The other types of oedema are lymphedema,
venous obstruction etc., The lymphedema does not pit on
pressure.
Pitting is demonstrated by applying sustained finger pressure on
the swelling (odema) and on release it will leave a depression.
There can be localised oedema in angioneurotic oedema and
urticaria.
THE HANDS AND FEET:
The Hands and Feet of the patient should be examined next. The
strength of grip, state of the joints, the character of the nails,
the presence or absence of finger clubbing (obliteration of angle
between nail bed and skin), koilonychias (soft, thin and brittle
and spoon shaped).the presence of nail bed infarcts, staining,
tremors, erythemas, petichia are to be observed. THE NECK should be
inspected and palpated next. Swellings in the neck are usually best
felt from behind. Cervical nodes and thyroid gland, submandibular
salivary gland or any masses are to be noted down.
Observe the trachea from front for any deviation.
Pulsations in the vessels must be noted. Any arterial pulsation
is both seen and felt as a distinct thrust, whereas venous
pulsation can be seen but not felt as a thrust.
THE BREASTS
The examination of breast is a necessary feature of general
examination of every woman especially nulliparous women, spinsters
and women with a family history of breast cancer. Examine the
symmetry, nipple, areola and the skin for ulceration, discharge,
retraction of nipple, and peau de orange (orange peel appearance).
Palpate each breast with palm in all the quadrants of breast for
any mass lesion and its relation to deeper structures.
Male breast is examined for any mass, and it is likely to be fat
or a palpable disc of breast tissue beneath the areola in younger
individuals or gynacomastia.
AXILLAE
Axilla is examined for any enlarged lymphnodes.
The arm is then lowered in the flexed position to rest across
the examiner's arm and palpation is continued from downwards along
the chest wall using fingers.
TEMPERATURE
Before taking the temperature, the thermometer should be washed
in antiseptic solution or in cold water, and well shaken so that
the mercury is brought down and after taking temperature it should
be washed well. The thermometer must be accurate and use a
thermometer (either be in the centigrade (Celsius) scale or
Fahrenheit scale) which ever is familiar. The thermometer is kept
well below the tongue and held firmly with the lip in adults and
grown up children and in infants the axilla is the choice. It
should be kept for a full minute. For collapsed, comatosed and
elderly patients, rectal temperature can be recorded.
FEVER
A rise in temperature beyond the normal (37C or 98.6F) is called
fever or pyrexia. The fever could be continuous when fever does not
fluctuate more than about 1'C (1.5'F) during 24 hours, but at no
time touches the normal. Fever is Remittent when the daily
fluctuations exceed 2'C, and intermittent when fever is present
only for several hours during the day. When a paroxysm of
intermittent fever occurs daily, the fever is described as
quotidian; when on alternate days, it is tertian; when two days
intervene between consecutive attacks, it is quartan. These
classical types are of fevers are not encountered frequently.
PULSE
Count the pulse for a full half minute when the patient is at
rest and composed. The rate in health during the stress of a
medical examination varies from about 60 to 80 beats / minute. The
common causes of a rapid pulse are recent exercise, excitement or
anxiety, shock, fever and thyrotoxicosis. A slow pulse is
characteristic of severe hypothyroidism and of complete heart
block.
RESPIRATION
Count the patient's respirations for a full minute, starting
when the patient's attention is elsewhere. It is convenient to do
this when the patient thinks you are still counting the pulse. The
normal rate in an adult is about 1418 / minute. Observe the
breathing and record if it is noisy. The noisy breathing could be
because of obstruction in the nasal passages, larynx, trachea,
bronchi. Also observe the pattern of breathing.
ODOURS
The odours can also give some leading information. The smell of
alcohol and paraldehyde are easily recognizable on the breath. The
odour of diabetic ketosis has been described as 'sweet and sickly';
that of uraemia as 'ammoniacal or fishy'; and that of hepatic
failure as 'mousy', but too much reliance on such delicate
distinctions is unwise. Halitosis (bad breath) is common in
patients whose dental hygiene has been poor, and is associated
especially with chronic gingivitis (periodontal or gum
disease).
ROUTINE PHYSICAL EXAMINATION
The object of a routine examination is to check the different
body systems to exclude abnormality. In considering symptoms
related to the patient's presenting complaint a more focused and
detailed examination is necessary.
EYES
The examination of the eye forms an important aspect of
examination and consists of the following:Simple tests of visual
acuity: compare one eye against the other.
Look for Exophthalmos or enophthalmos, Ptosis and oedema of the
lids.
Conjunctivae: Anaemia (pallor), Jaundice (yellowish
discolouration) or Inflammation
Pupils: Size, Equality, Regularity, Reaction to light,
Accommodation
Eye movement: Nystagmus, Strabismus.
Ophthalmoscopic examination of the fundi and ocular
chambers.
FACE
Facies, jaw movements, Facial symmetry or asymmetry, Rash,
Features of endocrine disease or hyperlipidaemia.
MOUTH AND PHARYNX
(torch and tongue depressor should be used)
Breath odours Lips: colour and eruptions Tongue: protrusion and
appearance Teeth and gums (if patient has dentures, notice whether
they fit properly and reasons for wearing)
Buccal mucous membrane: colour and pigmentation.
PHARYNX
Movement of Soft Palate. State of Tonsils.
NECK
Movement, pain and range, Veins, Lymphatic glands, Thyroid,
Carotid pulses and bruits.
UPPER LIMBS
General examination of arms and hands.
Fingernails: Clubbing or Koilonychias.
Pulse: Rate, Rhythm, Volume and Character.
Blood pressure
State of the arterial wall of radials and brachials
Axillae: Lymph glands.
Muscles: Muscle wasting, Fasciculation, Tests for power, tone,
reflexes and coordination
Cutaneous sensation: check all modalities to exclude root or
nerve lesions
Joints: movement, pain and swelling; rheumatiod nodules and
xanthelasma at elbows.
THORAX
Examine Anterlorly and laterally for:
Type of chest, asymmetry if any,
Breasts and nipples,
Respiration: rate, depth and character,
Pulsations, Dilated vessels, Position of trachea.
Look for and palpate apex beat
Palpate over precardium for thrills.
Palpate respiratory movements
Estimate tactile vocal fremitus
Percuss the lungs.
Auscultate the heart sounds
Auscultate the breath sounds
Estimate vocal resonance.
Cervical and Axillary glands.
Examine Posteriorly (patient sitting) for:
Respiratory movement
Estimate tactile vocal fremitus
Percuss the lung resonance
Auscultate the breath sounds
Estimate vocal resonance
Movements and deformities of the spine
Palpate from behind: cervical glands and thyroid.
Look for sacral oedema.
ABDOMEN
Inspection: size, distension, symmetry.
Abdominal wall: movement, scars, dilated vessels
Visible peristalsis or pulsation
Pubic hair
Hernial orifices
Palpation: Tenderness, Rigidity, Hyperaesthesia,
splashing, masses, liver, gallbladder, spleen,
kidneys, bladder
Percussion: masses, liver, spleen, bladder
Auscultation: bowel sounds, murmurs
Impulse on coughing at hernial orifices
Inguinal glands
Male genitalia: penis, scrotum, spermatic cord;
female genitalia: examine if relevant
Abdominal reflexes
Rectal examination when ever indicated
Gynaecological examination when ever indicated.
LOWER TIMBS
General examination of legs and feet, Stance, balance and gait,
Oedema of feet and ankles, Varicose veins,
Muscles: muscle wasting, fasciculation, tests for power, tone,
reflexes (including plantar response) and coordination
Joints: movement, pain and swelling, Peripheral pulses,
Temperature of feetFormulating a Diagnosis:
On complition of the history and examination, the clinician has
usually come to a working diagnosis. This is supported by further
investigations and subsequent progress of the disease. Sometimes it
is difficult to diagnose a patients problem which may be linked to
inexperience or the disease is in a stage of resolution or may be
in early stages of presentation. It is worthwhile working on the
diagnosis by first indentifying the system involved.
Case No
Name of the Patient:
Age:
Sex:
Occupation:
Race:
Religion
Nationality
Place:
Presenting Complaints with Duration
(in Chronological order)
History of Present illness
Past history (from Childhood)
Previous treatment / drug intake / Drug abuse/ drug allergy if
any
Family History
Occupational history
Menstrual history
Age of Menarche
Menstrual history
Obstetric history
Para .. Gravida.
Age of menopause
Daily habits/routine
Systemic enquiry
Physical Examination (General)
Systemic examination ( Should include examination of all the
relevant systems)
Summary of the Case
Provisional Diagnosis:
Laboratory Investigations (Clinical lab and Imaging)
Definitive Diagnosis
Suggested Treatment
Follow-up.
Date:
Case No 2:
Name of the Patient:
Age:
Sex:
Occupation:
Race:
Religion
Nationality
Place:
Presenting Complaints with Duration
(in Chronological order)
History of Present illness
Past history (from Childhood)
Previous treatment / drug intake / Drug abuse/ drug allergy if
any
Family History
Occupational history
Menstrual history
Age of Menarche
Menstrual history
Obstetric history
Para .. Gravida.
Age of menopause
Daily habits/routine
Systemic enquiry
Physical Examination (General)
Systemic examination ( Should include examination of all the
relevant systems)
Summary of the Case
Provisional Diagnosis:
Laboratory Investigations (Clinical lab and Imaging)
Definitive Diagnosis
Suggested Treatment
Follow-up.
Date:
Case No 3:
Name of the Patient:
Age:
Sex:
Occupation:
Race:
Religion
Nationality
Place:
Presenting Complaints with Duration
(in Chronological order)
History of Present illness
Past history (from Childhood)
Previous treatment / drug intake / Drug abuse/ drug allergy if
any
Family History
Occupational history
Menstrual history
Age of Menarche
Menstrual history
Obstetric history
Para .. Gravida.
Age of menopause
Daily habits/routine
Systemic enquiry
Physical Examination (General)
Systemic examination ( Should include examination of all the
relevant systems)
Summary of the Case
Provisional Diagnosis:
Laboratory Investigations (Clinical lab and Imaging)
Definitive Diagnosis
Suggested Treatment
Follow-up.
Date:
Case No 4:
Name of the Patient:
Age:
Sex:
Occupation:
Race:
Religion
Nationality
Place:
Presenting Complaints with Duration
(in Chronological order)
History of Present illness
Past history (from Childhood)
Previous treatment / drug intake / Drug abuse/ drug allergy if
any
Family History
Occupational history
Menstrual history
Age of Menarche
Menstrual history
Obstetric history
Para .. Gravida.
Age of menopause
Daily habits/routine
Systemic enquiry
Physical Examination (General)
Systemic examination ( Should include examination of all the
relevant systems)
Summary of the Case
Provisional Diagnosis:
Laboratory Investigations (Clinical lab and Imaging)
Definitive Diagnosis
Suggested Treatment
Follow-up.
Date:
Case No 5:
Name of the Patient:
Age:
Sex:
Occupation:
Race:
Religion
Nationality
Place:
Presenting Complaints with Duration
(in Chronological order)
History of Present illness
Past history (from Childhood)
Previous treatment / drug intake / Drug abuse/ drug allergy if
any
Family History
Occupational history
Menstrual history
Age of Menarche
Menstrual history
Obstetric history
Para .. Gravida.
Age of menopause
Daily habits/routine
Systemic enquiry
Physical Examination (General)
Systemic examination ( Should include examination of all the
relevant systems)
Summary of the Case
Provisional Diagnosis:
Laboratory Investigations (Clinical lab and Imaging)
Definitive Diagnosis
Suggested Treatment
Follow-up.
Date:
14