History taking and physical examination

History taking Taking a history Taking a history from a patient is the start of an important process for the patient and the health care professional. It is a conversation with a purpose and as a health care professional you will use many interpersonal skills to make sure you establish all relevant information in order to improve the health of your patient. Thus the conversation has three aims: To provide a trusting and supportive relationship To gather information To give information

Taking a history from a patient is a skill necessary for examinations and afterwards as a practicing doctor, It tests both your communication skills as well as your knowledge about what to ask. Specific questions vary depending on what type of history. In practice you may sometimes need to gather a collateral history from a relative, friend. This may be with a child or an adult with impaired mental state.

KEY ELEMENTS Introduce yourself,(name and position) Rapport with patient, Beginning start with open ended questions, Follow structural format, End, Summarize and have you got anything else to say,

Open ended questions Tell me what made you to come here Tell me more about, What do you think about, Is there any thing else to tell,

Identification data Name, Age, Sex, Race, Date of birth, Address, Referrals used,

Standard format Chief complaints(chronological order) History of Present illness, Past history, Drug history/allergies Family history Social and occupational history,

Chief complaints Example, Fever-2 weeks, Productive cough-1 week, Vomiting -2 days, Fatigue-1day,

History taking O L D C A R T Presenting complaint Onset (When did the pain begin?) O Location (Where is the pain, does it go anywhere else?) L Duration (How long does the pain last? Is it constant or intermittent?) D Characteristics (Is the pain sharp, shooting, burning, electrical? Is it a dull, aching or grinding pain? Does the pain feel like cramping or squeezing?) C Aggravating factors (Do activities like moving, walking, sitting, turning or touching worsen the pain?) A Relieving factors (What medical and non medical interventions relieve the pain?) R Treatment (What treatment has the patient tried e.g. heat, elevation, simple pain relief, rest?) T Presenting complaint This outlines the reason why the patient is seeking health care and should consist of two to three words. For example: Central chest pain Abdominal pain Pain in ankle Shortness of breath   History of presenting complaint (HPC)

Present illness Fever, Duration/Onset, Diurnal variation, Type of fever, Associated factors, Aggravating and relieving factors,

Example (FEVER)Present illness Fever since 2 weeks, to begin with it was mild fever, present through out the day, Associated with chills and rigors, Relieves after taking Tylenol, No skin rashes, No seizures/convulsions, No diarrhea/no abdominal pain,

History of presenting complaint (HPC) Gain as much information you can about the specific complaint. Sticking with chest pain as an example you should ask: Site: Where exactly is the pain? Onset: When did it start, was it constant/intermittent, gradual/ sudden? Character: What is the pain like e.g. sharp, burning, tight? Radiation: Does it radiate/move anywhere? Associations: Is there anything else associated with the pain e.g. sweating, vomiting Time course: Does it follow any time pattern, how long did it last? Exacerbating/relieving factors: Does anything make it better or worse? Severity: How severe is the pain, consider using the 1-10 scale?

Past history No similar complaints in the past, No history of hospitalization No previous surgeries, No history of Diabetes/Hypertension No history of epilepsy No drug allergies,

Family history Any illness run in your family? Similar history in the family, Parents and siblings suffering with any chronic illness, You should be able to collect relevant family history depending upon the present illness. Example, Patient has come due anemia , Try to R/O sickle cell, thalasemia/G6PD deficiency

History taking Family History Social history It is important to establish whether there are any genetically transmitted diseases within families, these include, coronary artery disease, hypertension, elevated cholesterol disease, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse and allergies Social history It is important to also establish the context in which the patients live as such factors can have an impact on an individual’s health. Such as occupation, drug (illicit) and alcohol consumption, hobbies, family situation and domestic violence. 

If patient has presented with febrile Convulsions, family history of epilepsy, If patient present with infective disease like Tuberculosis,  family history of T.B.

Social and occupational history Smoking, (how many packets/day) Alcohol(What he drinks, how much) And drug addiction Exposure to chemicals, The duration of the exposure,

Pediatric cases Includes, Pregnancy and illness during pregnancy, Is it full term and normal delivery/L.S.C.S Developmental history,(milestones) Immunization history

General examination Whether patient is conscious, Oriented to place/person/time, His built, nourishment, Dehydrated, depressed, distress, Anxious,

General examination Level of consciousness, Built and nutrition, Cyanosis, Clubbing Anemia, Jaundice, Recording B.P, Temperature, Pulse,

Definition Bluish discoloration of skin or mucous membrane caused by excess amounts of reduced hemoglobin or abnormal hemoglobin. 5% of reduced Hb in capillaries required for cyanosis to be apparent.

Cyanosis Bluish discoloration of the skin and mucous membrane, Due to increased amount of reduced hemoglobin(more than 5%)

Central cyanosis is caused by decreased SaO2(increased amount of reduced Hb) Central cyanosis only occurs when the oxygen saturation of arterial blood is less than 85%.

Central cyanosis Look on Tip of the tongue, Lips, Nose, Mucous membrane, Relieved by O2 Peripheral cyanosis Skin, Localized to one part

Peripheral Cool Cyanosis fades Cyanosis Skin temp. Massage or warming Central Warm No change Peripheral Cool Cyanosis fades

Causes Cardiac causes Cyanotic congenital heart diseases Eisenmenger’s syndrome C.C.F Respiratory causes, Chronic obstructive pulmonary disease, Collapse and fibrosis of the lung Pulmonary A.V. fistulas, High altitude,

Differential cyanosis Cyanosis in the lower limbs, PDA, Coarctation of the aorta, Differential cyanosis

Clubbing Definition Enlargement of soft parts of the terminal phalanges with both longitudinal and transverse curving of the nails. Grades of the clubbing 1.Softening of the nail bed, 2.Obliteration of the angle of the nail, 3.Swelling of the subcutaneous tissue over the base of the nail, 4.Hypertrophic pulmonary osteoarthropathy,

Clubbing, Schamroth's window test.

Causes Respiratory cause T.B Carcinoma of the lung Bronchiactasis Cystic fibrosis, Pulmonary fibrosis Cardiac Cyanotic congenital heart diseases. Bacterial endocarditis GIT causes Chron’s disease ulcerative colitis Biliary cirrhosis

Koilonychia jaundice

VITAL SIGNS Pulse rate, Blood pressure Respiratory rate, Temperature,

Clinical reasoning Assessment and plan

Identifying the problem and making diagnosis Steps in clinical reasoning Identify the abnormal finding Localize finding anatomically Interpret findings in terms of probable process. Make hypothesis about the nature of the patient’s problem Test the hypothesis and establish a working diagnosis Develop a plan agreeable to the patients

Systemic examination Involved system should be the first priority. The other system must be examined later. Differential diagnosis Final diagnosis Investigations, Treatment