CASE HISTORY&

CLINICAL EXAMINATION

DR. HAYDAR MUNEER

Case History

History-taking is the art of conversation and requires a fine balance between listening and interjecting with relevant questions to clarify points and obtain details as the history unfolds

Cure sometimes, treat often, comfort always.

Hippocrates

Chief complain This is one or two words

summary of the patients main symptoms by the patients own words

History of present illness This is in details description of the

main symptom Try to put the important positive

first Include the relevant negative Be very clear about chronology of

events

Ask about thyroid problems: TB Hypertension Rheumatic fever Epilepsy Asthma Diabetes

Asking have you ever had any medical problem or been hospitalized for any thing ?

Past Medical History

Social History

At what time did they eat or drink ?

Who will look after the patient, do they need help to mobilize ?

Smocking and alcohol ?

Connect ……

SOCRATESSiteOnsetCharacteristic RadiationAssociation symptomsTimingExacerbating or relieving factorSurgical history

CLINICAL EXAMINATION

Clinical ExaminationThe most important aspect of clinical examination is for the clinician to know what you look for ..Leonardo da vinci call thisSaper vedere or..‘Knowing how to see’

General principles

1. Inspection2. Palpation3. Percussion 4. Auscultation

Examination of ulcer1. Floor of an ulcer2. Base of ulcer3. Edge of ulcer4. Site of ulcer 5. Shape of ulcer6. Pain7. Duration8. Lymph node 9. Histopathological examination

Examination of lump1. Position, location, shape and size2. Inflammatory characteristics Hot Tenderness Redness Gardinal signs of

infection Swelling Loss of function3. Mobility

4. Consistency, dullness and resonance: solid and hard tense, soft, cystic superficial fluid-containing cavity or

collection is fluctuant.

5. Transillumination: involves shining a light through a swelling to detect whether it transmits light brilliantly or not

WHAT IS THE DEFERENTIAL DIAGNOSIS

AND TREATMENT OPTIONS OF ?

50 years female patient present to the consular clinic complain from painless lump in the right parotid region 2*3 cm duration for 5 years ?

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