• Identify patient common complaints related to central nervous system (CNS) conditions

 • Explain the guidelines of examining nervous system

 • Describe the techniques used to examine the CNS (inspection, palpation, percussion auscultation)

 • Demonstrate skills in examining the CN

• What is examined in the motor system?

• Mention the common reflexes which are examined.

• What are the routine sensory tests which can be tested at bedside?

• Ask patient to perform small basic motor skills such as tracing or drawing an object or undressing themselves

 • Assess patients appearance, behaviour and communication: o Patients level of intelligence and education o Is the patient agitated or confused? o Is attention easily held? o Is the patient well-groomed or unkempt? o Does the patient show interest in their surroundings?

ü Define therapeutic relationship

ü Describe the characteristics of the therapeutic relationship




• Describe the boundaries of therapeutic relationship in history taking

 • Describe techniques for skilled interviewing   

 • Demonstrate therapeutic relationship skills during patient history taking

ü What is a therapeutic relationship?

 • What are the boundaries of therapeutic relationships?  

ü What are the behaviours which are unacceptable in a therapeutic relationship?

• What are the four the techniques for skilled interviewing

• Define patient history

ü Describe components of patient’s history

• Describe the process of taking patient’s history

• Demonstrate skills of taking patient’s history

• Define patient history.  

ü List and describe the components of patient’s history.

 • What do you do to reinforce the patient to tell their story about the illness they have?  

• Explain history taking in special situations

ü Identify specific situations that need special attention during history taking

• Describe the characteristics of each special situations in the process of history taking

 • Describe the techniques/skills needed during history taking in special situations   

• Demonstrate skills of taking history in special situations

   • What are the situations which can be difficult for the clinician during history taking?  

• What are the characteristics of a silent patient?

 • What are the techniques you can use to complete your history of a patient with altered hearing?

ü Define physical examination

ü Explain the preparations for physical examination

ü List equipment for physical examination

ü Describe the cardinal techniques of physical examination

 • Describe the sequence of physical examination  

ü Demonstrate skills in performing physical examination (head to toe)

ü What are the four cardinal techniques of physical examination?

• What is the essential equipment for physical examination?

 • What are the standard precautions to consider when conducting head to toe assessment?

ü Identify common symptoms and conditions of the respiratory system

• Describe the techniques for conducting respiratory system examination (inspection, palpation, percussion, auscultation)  

• Demonstrate skills in examining conducting the respiratory system examination

ü What things should be reported when inspecting the chest in respiratory examination?

ü What lung conditions which may displace mediastinum away from the lesion?

• Explain the basic principles of chest examination.

ü Identify common complaints (signs and symptoms) of patient with the disease of cardiovascular system

ü Describe the techniques used to examine the cardiovascular system inspection, palpation, percussion, auscultation

• Demonstrate skills in examining the cardiovascular system

ü What are the common complaints of patients with diseases of cardio-vascular system?

• Explain applied principles for cardio-vascular system examination.

• Describe how you can take blood pressure.

ü List the gastrointestinal signs and symptoms that call for gastrointestinal examination

• Describe the techniques used to examine different parts of the abdomen (inspection,  palpation, percussion auscultation)

• Describe the deep palpation of the liver, spleen and kidneys

• Demonstrate skills in examining the abdomen

ü What are the common symptoms of the common gastrointestinal conditions?

ü What do you report on inspection of the abdomen?

ü During palpation of the abdomen, what do you palpate for?

ü What are the possible causes of abdominal distension?

 There are four routine sensory modalities that can be tested at the bed side:

ü Light touch  

ü Position sense (the appreciation of passive movement)

ü   Vibration

ü   Pain

Reflex examination Examine deep reflexes with patella hammer: ƒ

ü  Triceps jerk ƒ

ü  Biceps jerk ƒ

ü  Supiator jerk  

ü  Jaw jerk ƒ

ü  Knee jerk ƒ

ü  Ankle jerk  ƒ

ü Clonuses


 Examine superficial reflexes with patella hammer ƒ

ü  Plantar reflex ƒ

ü  Abdominal reflex


Motor System Examination  

ü Begins when a patient enters the examination room (observation)  

ü  Observe any involuntary movements

ü Look for muscle bulk (normal, atrophy or hypertrophy) by comparing with the other side

ü Feel state of relaxed muscles to examine muscle tone  

ü  Ask patient to move body parts against some resistance to examine groups of muscles to examine muscle strange


The following are common complaints related to neurological disorders:

ü  Headache o Dizziness or vertigo

ü  Generalized, proximal, or distal weakness

ü  Numbness, abnormal or loss of sensations

ü  Loss of consciousness, syncope, or near syncope

ü  Seizures

ü  Tremors or involuntary movements


Motor system examination

ü  Muscle bulk ƒ

ü  Muscle tone ƒ

ü  Muscle power ƒ


ü Superficial and deep ƒ

ü Coordination ƒ

ü Involuntary movement

 The following is a brief but comprehensive guideline for neurological assessment:

ü Mental status examination

ü Gait examination

ü Cranial nerves examination

ü Motor system examination

ü  Sensory examination

Mental Status Examination  

ü A full mental status examination is very long, so initially a mini mental status examination is performed.

ü Determine level of consciousness using the Glasgow Coma Scale

ü  Orientation to time, place and person o Ask the patient where they are o Ask what time, day, date, year it is

ü  Determine patient’s short and long term memory o Read four words the patient knows and proceed with other parts of examination; after a few minutes ask them to repeat the words o Ask long term events depending on patient’s level of education and knowledge

During history taking and physical examination a clinician should know that the following behaviours are unacceptable

Ø Abuse (physical, emotional, verbal, sexual or financial)

Ø  Initiating a social/personal relationship with a patient

Ø  Neglect

Ø  Acting as a representative for patients under powers of attorney or representation agreements

Ø  Prejudice - neither the client nor the therapist should ever use racist or sexist language or behaviour, or express any prejudice based on characteristics such as religion, background, sexuality, marital status or other personal characteristics

 Strategies the clinician might consider using in maintaining therapeutic relationships during history taking include the following practices:

Ø Understanding the limits of the therapeutic relationship

Ø  Adhering to the plan of care

Ø  Communicating the expectations for and limits of confidentiality

Ø  Being sensitive to the context in which the care is provided

Ø  Implementing reflective practice o Concluding the therapeutic relationship

 For a clinician to be able to empower the patient, he can do the following:

Ø Take into consideration of the patient’s perspective  

Ø  Convey interest in the person

Ø  Follow the patient’s leads

Ø Elicit and validate emotional content

Ø Share information with the patient, especially at transition points during the visit.

Ø  Make your clinical reasoning transparent to the patient  

Ø  Revel the limits of your knowledge

 Other key pieces of information include:  

Ø Medications taken by patient, including name, dose, route and frequency of use. Also include list of home remedies and non-prescription drugs.

Ø  Allergies, including specific reaction to each medication such as rush or nausea must be recorded as well as allergies to foods, insects, or environmental factors

Ø  Tobacco use including type (i.e., packets of cigarettes, chewing tobacco, etc.)

Ø  Alcohol and drug use

 Provide information related to adult illness in each of the four areas:

Ø Medical: Illnesses such as diabetes, hypertension, hepatitis, asthma, and HIV; hospitalizations; number and gender of sexual partners, and risky sexual practices.

Ø  Surgical: Dates, indications and type of operations.

Ø Obstetric/gynaecologic: obstetric history, menstrual history, methods of contraception and sexual function.

Ø  Psychiatric: illness and time frame, diagnosis, hospitalizations, and treatments

 To reach a common understanding of the problem you need to explore the patient’s perspective in the four domains ƒ

Ø Patient’s feelings (fears and concerns)  ƒ

Ø Ideas about the nature and cause of the problem ƒ

Ø  Effect of the problem on patients function ƒ

Ø  Expectations of the disease and of the clinician.

 Planning for follow up and closing  

Ø Let the patient know that the end of the interview is approaching to allow time for them to ask final questions

Ø  Make sure that the patient understands the mutual plans you have developed

Ø  When you have finished and you want to close, you can say ‘We need to stop now, do you have any questions about what we have covered’?

Ø  Address any concerns that the patient will raise

Such situations include the following:  

Ø Patient becoming silent  

Ø  Confusing patient

Ø  Patient with altered capacity

Ø Talkative patient  

Ø Crying patient  

Ø Angry or disruptive patient

Ø  Interview across language barrier  

Ø  Patient with low literacy

Ø Patient with impaired hearing

Ø  Patient with impaired vision

Ø  Patient with limited intelligence

Ø  Patient with personal problems

 Clarify each critical symptom with these attributes: ƒ

Ø Location, quality (what is it like?)  ƒ

Ø  Quantity or severity (how often? how painful?)  ƒ

Ø Timing (when did or does it start?)  ƒ

Ø  Setting in which it occurs (include environmental factors, personal activities, etc.)  ƒ

Ø Remitting or exacerbating factors

Ø  Associated manifestations

 The skills needed to handle the situation include the following

Ø You should appear attentive and give brief encouragement to continue when appropriate

Ø  Watch the patient closely for non-verbal cues such as difficulty controlling emotions.

Ø  Patients with depression or dementia may lose their usual spontaneity of expression, give short answers to questions and then fall silent. If you have already tried to guide them through recent events or typical day, try shifting your inquiry to the symptoms of depression or begin an exploratory mental status examination.

Ø Silence may also be the patient’s response to how you treat them.   ƒ Are you asking too many questions? Did you offend the patient? At this point you may need to ask the patient directly ‘you seem very quiet. Have I done something to upset you’

Ø  The patient may have overwhelming symptoms like pain, nausea or dyspnoea.  

 The skills needed to handle the situation include the following

Ø Determine if the patient has the decision making capacity or the ability to understand information related to health to make preferences about treatment  o For patients with capacity, obtain consent before talking about their health with others

Ø  Even if patients communicate with facial expressions or gestures, you must maintain confidentiality and assure the patient

Ø Consider having two interviews, one with patient alone and the other with the patient and the relative (informant). Each of the two interviews has significance.

Ø  For patients with impaired capacity you will often need to find a surrogate informant or decision maker to assist with the patient’s history. o If not, in many cases a spouse or family member who can represent the patient’s wishes can fill this r o Apply the basic principles of interviewing to your conversations with patients’ relatives or friends  o Find a private place to talk

The skills needed to handle the situation include the following:

Ø Give the patient free rein for the first five to ten minutes, listen closely to the conversation. You may find that perhaps the patient simply needs a good listener and is expressing pent up concerns or the patient’s style is to tell stories

Ø Assess what the patient says, check if there are:  Signs of excessive details with the patient’s speech?  Flight of ideas of a disorganized thought process that could suggest thought disorder  ƒ Signs of confabulation?

Ø  Focus on what seems important to the patient  

Ø  Show your interest by asking questions in those areas

Ø  Interrupt only if necessary but be courteous o Remember that part of your task is to structure the interview to gain the important information about the patient’s health

Ø Do a brief summary to help you change the subject yet validate any concerns o Do not show your impatience, if time runs out explain the need for a second meeting

The skills needed to handle the situation include the following

Ø Usually crying is therapeutic, as is your quiet acceptance of the patient’s distress or pain

Ø  Offer a tissue and wait for a patient to recover

Ø  Make a supportive remark like, ‘I am glad you were able to express your feelings’, most patients will soon compose themselves and resume their story

Ø  Crying makes many people uncomfortable, learn how to accept displays of emotions so that as a clinician you can support patients at those moving and significant times

The Patient with Impaired Vision

Ø When meeting a blind person, shake hands to establish contact

Ø  Explain who you are and why you are there  

Ø  Orient the patient to the surrounding and report if anyone else is present in the room

Ø  Adjust the light

Ø  Encourage the patient to wear glasses whenever possible

Ø  Use only words to communicate because gestures cannot be seen by the patient

  The skills needed to handle the situation include the following:

Ø Ask relative when hearing loss occurred and ask for the patient’s method of communication  

Ø  If the patient communicates with sign language, and has come with a translator, use the translator to provide information

Ø  If the patient is not totally deaf, speak at normal volume and rate and do not let your voice trail off at the end of sentences

Ø  Avoid covering your mouth or looking down at papers while speaking. When closing, write out any instructions

.   The skills needed to handle the situation include the following:

Ø Make every effort to find a translator. A translator should be a neutral person who is familiar with both languages and cultures (that of a clinician and that of a patient)

Ø  Do not recruit the family member or friend as a translator:  confidentiality may be violated, meanings may be destroyed, and transmitted information may be incomplete.   

Ø  As you begin to work with the translator, establish rapport and review what information would be useful o Explain that you need a translator to translate everything, not to condense or summarize

Ø  Make your questions clear, short and simple  

Ø Speak directly to the patient even though the patient will get information through the translator (i.e., do not look at the translator when conveying information for the patient; look at the patient directly.)  ƒ For example: ‘How long have you been sick’? rather than ‘How long has the patient been sick’?

The skills needed to handle the situation include the following:

Ø Accept the angry feelings from patients  o Allow them to express such emotions without getting angry in return

Ø  Avoid joining such patients in their hostility to another provider, the clinic or the hospital even when privately you may feel sympathetic o You can validate their feelings without agreeing to their reasons   ƒ For example: ‘I can understand that you felt very frustrated by the long wait and answering the same question over and over. Our complex health system can seem very unsupportive when you are not feeling well’. When the patient has calmed down, help find steps to avert such situations in the future.

Ø  Rational solutions to emotional problems are not always possible and people need time to express and work through their angry feelings.

Ø  Some angry patients become overtly disruptive; they can disturb the clinic or emergency department very quickly. Before approaching such patients, alert the security staff.

Ø  As a clinician maintain a safe environment, stay calm, appear accepting and avoid being confrontational in return. 

 Some anger directed to the clinician may be justified if the clinician is:

Ø  Late for the appointment

Ø  Inconsiderate

Ø Insensitive Acting angry, short tempered, or frustrated

The characteristics of the heart, lung, and bowel sounds, including

ü Location

ü  Timing

ü  Duration

ü  pitch and

ü  intensity

Inspection Close observation of the details of the patient’s:

ü Appearance

ü  Behavior  

ü Movement  such as facial expression, mood, body habitus, and conditioning

ü  Skin conditions such as petechiae, or ecchymosis

ü  Eye movement  

ü  Pharyngeal colour

ü  Symmetry of thorax

ü  Height of jugular venous pulsation

ü Abdominal contour

ü  Lower extremity

ü  edema and gait

Palpation Tactile pressure from the palm, fingers or finger pads to assess

ü Areas of skin elevation , depression, warmth, or tenderness

ü  Lymph nodes, pulses

ü  Contours, and sizes of organs and masses

ü  Crepitus

Equipment includes the following:

ü A stethoscopes for auscultation

ü  Sphygmomanometer for measuring blood pressure

ü  A thermometer for measuring body temperature

ü  Cotton for testing the sense of light touch

ü  Gloves and lubricant for oral, vaginal and rectal examinations

Ø A penlight for inspection of hidden body parts like in the ears

Ø  Safety pins for testing two point discrimination

Ø  Watch with second hand for evaluation of pulse

Ø  Ophthalmoscope, otoscope for examination of eyes and ears

Ø  Patella hammer for examining reflex

Ø  Tape measures for evaluation of lengths

Ø Tongue depressor for examination of throat

Ø  Vaginal specula for vaginal examination in the joints

Before you begin physical examination, take some time to prepare for the task ahead.

Ø Reflect your approach to the patient: o Try to appear calm, organized, a

Ø Prepare the environment

Ø Prepare and check your equipment Check if they are all available and are working  

Ø Make the patient comfortable  

Ø Showing concern for privacy and patient modesty must be ingrained in your professional behavior.   ƒ

Ø Ensure that the patient consents for the procedure before continuing

 These attributes make the patient feel respected and at easy: ƒ

Ø Describe the procedure to the patient before preparing them  ƒ

Ø Ensure that the patient consents for the procedure before continuing ƒ

Ø Keep the patient informed throughout the procedure especially when you anticipate embarrassment or discomfort, for example, when you move to checking the femoral puls

Taking Vital Signs This step is part of examination; however, it may need to be done before undressing the patient. In many facilities it is done before the patient is seen by the clinician as a baseline assessment.  

ü Measure the blood pressure

ü  Count the pulse and respiratory rate

ü  If indicated, measure the body temperature

ü  Document findings

Common symptoms of the respiratory system include the following:  

ü Chest pain

ü  Shortness of breath (dyspnoea)

ü  Wheezing

ü  Cough  

ü  Blood streak sputum (haemoptysis

Techniques for Conducting Respiratory System Examination: Inspection of the Chest

Ø The normal chest is bilaterally symmetrical and elliptical in cross-section.

Ø The chest may be destroyed by disease of the ribs or spinal vertebrae as well as by underlying lung diseases.

Ø  Kyphosis (forward bending) and Scoliosis (Lateral bending) may cause asymmetry of the chest.

Ø  See if there is any previous surgical or traumatic scarring or tattoos

Ø  Inspect for masses or lumps

Ø  Pectus excavatum – sternum sunken into the chest.

Ø  Pectus carinatum – sternum protruding from the chest.

Ø Movement of the chest, normal chest moves with respiration and it moves equally on both sides

Signs of Respiratory Distress That Can Be Inspected  

Ø Cyanosis – person turns blue centrally or peripherally

Ø  Chest in drawing

Ø  Accessory muscle use

Ø  Diaphragmatic Paradox – the diaphragm moves opposite of the normal direction on inspiration, suspect flail segment in trauma


Techniques for Conducting Respiratory System Examination: Palpation of Chest

Ø Locate the mediastinal position by locating the position of the trachea

Ø  Identify apex beat

Ø Examine chest expansion

Ø  Perform tactile vocal fremitus (TVF)

Ø  Palpate any part of the chest and identify pathological defect

Ø  In recent injury palpate for pain and tenderness  

Findings from Palpation

Ø Asymmetrical chest expansion may be detected during palpation

The mediastinum may be pushed away from the affected side by:

Ø Pleural effusion

Ø  Pneumothorax

Ø  Empyema

Ø  Haemopneumothorax

The mediastinum may be pulled to the affected side by:

Ø Lung fibrosis

Ø Lung collapse

Tactile vocal fremitus is detected by palpation (but this is not a commonly used routine examination technique)

Ø Vocal fremitus is the perception of vibrations produced by sound on the chest wall. They are reported as normal, increased or reduced.

Ø Note that anything which hardens the lungs  substance, such as consolidation in Pneumonia or Tuberculosis will increase the vocal fremitus

Ø  Pneumothorax, or fluid in the pleural cavity, will reduce the vocal fremitus


Findings from Percussion in the chest

Ø Normal chest finding is a resonant percussion note

Ø Dullness indicates consolidation as in pneumonia

Ø  Stone dullness indicates fluid stimulated by percussion off a wall made of bricks

Ø  Hyper resonance (as can be detected  by percussing  the inflated cheek) suggests a presence of excess air in the lung (pneumothorax, Chronic broncho asthma)

Ø  Percussion over the precardium area is dull (cardiac dullness

Techniques for Conducting Respiratory System Examination: Auscultation of the Chest  

Ø Here we use a stethoscope to detect the sounds transmitted in large airways. The structure of the lung will affect the way in which these sounds are perceived by the ears.

Ø  Breath sound is a normal if it is a vesicular sound.

Ø  Broncho breathing sound suggests consolidation or fibrosis.   

Ø  The sounds of broncho breathing is generated by turbulent airflow in large airways and similar sounds can be heard in healthy patients by listening over the trachea.  

Ø Findings from Auscultation  Vocal resonance o If you ask the patient to pronounce some syllables and auscultate the vibrations on the chest wall, what you hear is called vocal resonance. It is louder in conditions which the lungs are hardened (consolidation) and reduced in pleural effusion and lung collapse.

Ø  Crackles may represent opening of small airways and alveoli. They may be normal at the lung base if they clear on coughing or a few deep breaths.

Ø  Basal crackles are classical features of pulmonary congestion with left ventricular failure. They may be more diffuse in pulmonary fibrosis

Ø By listening the breath sound, one can assess the quantity of the air being drawn in the lungs. It is usually reported as normal, reduced, or absent air ent

Per form systemic respiratory examination by following these principles (IPPA):

Ø Inspection

Ø Palpatio

Ø  Percussion

Ø Auscultation

Respiratory distress can be seen when there is

Ø Central or peripheral cyanosis

Ø Intercostals in drawing and

Ø The use of accessory muscles

Common symptoms of the cardiovascular system include the following:

ü Chest pain

ü  Palpitations

ü Swelling or edemas

ü  Cyanosis  

ü  Anemia

 During examination of cardiovascular system:  Observe the patient for general signs of cardiovascular disease such as finger clubbing, cyanosis, lower limb edema and anemia check for: ƒ

Ø Pulse rate ƒ

Ø Blood pressure ƒ

Ø  Jugular venous pressure  ƒ

Ø Pericardium area.


Arterial Pulses

Ø Describe the characteristic of pulse such as rate, rhythm and volume

Ø  Compress the radial artery with your index and middle finger

Ø  Record whether pulse is regular or irregular

Ø  Count the pulse for one minute concretive

Ø  Normal pulse rate in adult is 60 to 100 per minute

Ø  Less than 60 is Bradycardia and   above 100 is Tachycardia

Assessing the Jugular Venous Pressure (JVP)  

Ø Position the patient supine with the head off the table elevated at 45 degrees

Ø  Look for a rapid, double (sometimes triple) wave with each heart beat

Ø  Use light pressure just above the sternal end of the clavicle to eliminate the pulsations and rule out a carotid origin

Ø  Causes of raised JVP are due to increased pressure in right atrium producing engorgement of neck veins.

Ø  Some of causes include congestive cardiac failure (CCF), tricuspid valve disease, constrictive pericarditis, superior vena cava obstruction.

The following are common symptoms of gastrointestinal disorders:

Ø Abdominal pain, acute and chronic

Ø  Indigestion, nausea, vomiting including blood, loss of appetite, early satiety

Ø  Dysphagia and/ or odynophagia

Ø  Change in bowel function  

Ø Diarrhoea, constipation

Ø  Jaundice

 Generalized distension of the abdomen is caused by one of five F’s, namely:

Ø Fluid (Ascites)  

Ø Fetus  

Ø  Faeces  

Ø  Fat

Ø  Flatus


Inspection of the Abdomen  • Stand back and examine the abdomen from the end of the bed • Move to the patient’s right-hand side and kneel on a level with the abdomen • If you attempt to examine the abdomen while standing, you will not be able to observe it closely and you will be forced to extend your arm so much you will lose accuracy when palpating. • Look at the shape of the abdomen

Nerves sequence 1.

 I: Olfactory  

2. II: Optic  

3. III-IV-VI: Extraoculars

 4. V: Trigeminal

 5. VII: Facial  

6. VIII: Vestibulocochlear  

7. IX-X: Glossopharyngeal, Vagus  

8. XI: Accessory

 9. XII: Hypoglossal   

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