Este ok pentru mine să vă pun câteva întrebări ??

INTRO

1. What is your name: cum va numiti

2. How old are you: câți ani aveti/ai
3. Where do you live: Unde locuiesti
4. Where were you born: Unde v-aţi născut
5. When were you hospitalised: cand v-ati internat in spital
6. Have you been hospitalised through emergency or programme: Ati fost internat(a) prin
urgenţă sau programare

CHIEF COMPLAINTS

1. What health problem bought you to the hospital: Cu ce problema de sanatate ați venit la
spital

FAMILY HISTORY

1. Do you have any family members with health problems: aveți membri de familie cu
probleme de sănătate

IF PATIENT IS FEMALE

1. At what age did you have your first period: la ce vârstă ati avut primul ciclu
2. Are periods regular: Ciclul menstrual este regulat
3. Date of last menstrual cycle: data ultimei menstruatii
4. How many childbirths do you have: cate nashteri aveti
5. Any Abortions : vreun avort
6. At what age did menopause start : La ce vârstă a început menopauza

PREVIOUS DISEASES

1. Do you have any other diseases or problems with you : aveți alte boli sau probleme
2. How long have you had the disease: De cand aveti boala
3. When were you diagnosed: când ati fost diagnosticat/a
4. What diagnostic tests were performed : Ce teste de diagnostic au fost efectuate
5. Did you have any treatment for the disease: Ati facut tratament
6. What medication did you take: ce medicamente ati luat

CONDITIONS OF LIFE (Social History and Habits)

1. Do you live in an apartment or house: stati intr-un apartament sau casa

2. What do you eat and how much: Ce mancati si in ce cantitate
3. What is your occupation: Cu ce va ocupati
4. Do you have hard physical work: aveți muncă fizică grea
5. Do you have stress at work: sunteti stresat(a)
6. Do you have any children: Aveti copii
7. Do you live alone or with family: locuiti singur(a) sau cu familia
8. Do you smoke : Sunteti fumator / fumatoare
9. Do you drink alcohol : Consumati alcool
10. Do you drink coffee : beti cafea/ceai
11. Do you have any allergies : aveți alergii
MEDICATION

1. Do you take any Medication : Luati vreun medicament?

HISTORY OF DISEASE

1. When did the pain start : când a început durerea

2. Did the pain start suddenly: durerea a inceput brusc
3. Where did the pain first start : unde a inceput durerea?
4. Is the pain radiating somewhere : durerea radiaza undeva
5. How intense is the pain : cât de intensa este durerea
6. How long does the pain last : cât timp dureaza durerea?
7. How do you feel the pain, sharp, dull : cum simti durerea? Ascutita sau ..
8. Does the pain cause you other problems : durerea va cauzeaza alte probleme
9. What makes the pain better : ce va amelioreaza durerea
10. What makes the pain worse : Ce face durerea mai rea
11. Is there a special time of day you feel the pain : exista o perioada speciala in
timpul zilei in care simtiti durerea?

• What tests have you had previously : Ce teste ati avut anterior

REMEMBER THE FOLLOWING:

• Dates for everything relevant

• Analysis of symptoms
• Any Treatment/ Investigations leading upto diagnosis

PHYSICAL EXAMINATION

* Remember to examine from the Right Side and get patients consent.

• State of Consciousness
• State of Nutrition (pinch: M = 1.5cm, F = 2cm)

2
+ Grade 1 BMI: 25-29.9 kg/m
2
+ Grade 2 BMI: 30-39.9 kg/m
2
+ Grade 3 BMI: ≥40 kg/m

• Face, Skin, Mucosa, Palms (signs of cyanosis, jaundice etc)

• Temperature – Bilateral
• Sclera and Conjunctiva
• Lips, Tongue and Buccal Mucosa
• Ear Lobes, Hair
• Thorax, upper and lower extremities
• Lymph Nodes – not in sem1 exam!

​ ​
RESPIRATORY EXAMINATION

Inspection
 1. Permeability of nose: compress 1 nostril and ask patient to breathe in and out via
nose, and then compress other nostril.
2. Nasal Septum: 4 fingers on forehead, use thumb to raise nose and check if septum is
straight.
3. Sinus Inflammation: compress the following with the thumb
• Inner limits of eyebrows, 1 at a time – Frontal Sinus
• Inner corner of eye – Ethmoidal Sinus
• On Zygomatic Bone – Maxillary Sinus

4. Thorax Form: normal, barrel, pigeon, funnel?

5. Respiratory Rate & Pattern of Breathing: (16-20 b/m)
6. Digits – clubbing, cyanosis, nicotine staining?

Palpation

• Must check for Amplitude and Vocal Fremitus

• Must ask patient to expose upper body and sit up straight
• Place hands in butterfly fashion to observe expansion

Amplitude: ask patient to breathe and observe symmetry.

1. From the posterior, place finger tips in supra clavicular fossa, thumbs on either side of
spine (paravertebral).
2. Then observe the same for Intrascapular and vertebral spaces until base of lung.
Fremitus: ask patient to say “33” and feel fremitus (vibration)
1. Anterior
2. Posterior
3. Paravertebral
4. Base of Lungs
5. Lateral

Percussion

• Remember to use middle phalanx of middle finger of right hand!

1. Supraclavicular Fossa
2. Supraspinous (across trapezius closest to spine, middle, lateral)
3. Paravertebral (each ICS between scapula)
4. Base of the lungs
* HERTZ MANEUVER – Norm = +ve
5. Ask Patient to place hands on head and percuss lateral aspect
6. Ask patient to lay down, Anterior R & L mid clavicular line:
nd th th
* R = 2 – 5 ICS (or possibly 6 until you reach hepatic dullness- sup liver)
nd rd
* L = 2 and 3 ICS as you reach dullness of heart.

Auscultation

• Stethoscope on all points of percussion

• Ask patient to breath in and out on each
• For apex and base of lungs ask patient to cough

DIGESTIVE EXAMINATION

* Remember to examine from the Right side, ask patient to flex legs to relax the abdominal
muscles, and remove socks!

Inspection
General Inspection:
• Face, Skin, Mucosa, Palms (signs of cyanosis, jaundice etc)
• Temperature – Bilateral
• Sclera and Conjunctiva (ochii sus)
• Upper and Lower extremities (edema, skin abnormalities, scars etc)
Local Inspection:
• Ask Patient to open mouth, Teeth, gums & Buccal Mucosa (Gingivitis)
• Ask Patient to raise tongue, dilated veins? (Portal Hypertension)
• Ask Patient to swallow, discomfort?
• Ask Patient if they have been vomiting?
• Ask Patient if they recall colour of vomit? (Hematemesis – blood, Ground Coffee aspect)
• Observe Abdomen for: Mobility with respiration, scarring (interventions), collateral
circulation (portal hypertension)

Palpation

* Superficial Palpation, followed by Deep Palpation:

• LIF, LF, LHC
• E, RHC, RF
• RIF, HG, MG

* Leave painful points until last:

1. Epigastric – Gastroduodenal ulcers

2. Cystic – Gall stones or Cholecystitis
3. Mesenteric (paraumbilical) – Diarrhea
4. Ovaries points – in each IF lower midline – inflam/infec of fallopian tubes
5. Appendix: appendicitis
• Lantz - joining point of 1/3 Right with 2/3 Left on the bi-spinous line.
• Mc Burney – Half way between ASIS and umbilicus.

Percussion

* always perform superior à inferior

•E à HG
• Radial aspects x 2 (25 and 45 degrees)
• Wave Sign (palm resting on one flank, percuss opposite site to feel for wave)

LIVER EXAMINATION

Percussion & Palpation

• Legs must be flexed just like in abdominal exam

nd th
• Start Right Mid clavicular line at 2 ICS down to 5 ICS (sup limit of liver)
• Continue below ribs until hepatic dullness terminates (inf limit)
• Confirm inferior limit by palpation, asking patient to breathe in and out (should feel liver
on deep inhalation)
• Estimate size of liver (N=10cm, Hepato= 11cm, Atrophy= 9cm)
• Feel the edge, then feel the shape (L Lobe is 4cm inferior to xiphoid)

SPLEEN EXAMINATION
 • Ask patient to lay on Right side with Left leg Flexed
• Spleen not palpable unless splenomegally!!
th th
• Percussion – 9 – 11 ICS posterior axillary line to anterior.

Ask patient about the aspect of the stools (colour, odour, rectoragia)