Download presentation
Presentation is loading. Please wait.
1
HISTORY TAKING & GENERAL EXAMINATION
By Dr. Zahoor
2
History Taking Important Points
Look confident Welcome the patient saying Asalam O Alaikum Shake hand with patient Introduce yourself – I am so and so medical student
3
Important Points Explain that you wish to ask some questions to find out what happened Make sure patient is comfortable and curtains are in place Confirm patient’s name, age, occupation
4
Importance of History Ask principal symptoms with duration and allow the patient to describe Inquire about the sequence of symptoms and events Don’t ask leading questions in the beginning
5
Usual Sequence of History
Chief complaint with duration 2. History of present illness 3. Past history e.g. past illness, admission in hospital, surgery 4. Family history 5. Personal and social history – smoker/not, travel, pet, animal contact - Drug history including allergies
6
1. Chief complaint with duration
Patient c/o chest pain – 2 months 2. History of present illness Ask when he was completely well? Then what happened and then describe symptoms in chronological order of onset
7
Example Chest pain – 2 months Ask
Site of pain , one set acute or gradual Character – feeling pressure, dull, stabbing, shooting Radiation
8
Example (cont) Severity – interfere with work or sleep
Precipitating and relieving factors H/O this pain before Pain associated with nausea, sweating e.g. angina Note – When patient is unable to give history, then get necessary information from friends, relative
9
3. Past history Ask for Previous illness, hospital admission
Any operations (if yes, when it was done and what was the problem) Medicines
10
4. Family History Ask about Parents – father and mother are alright
Any history of hypertension, diabetes mellitus If history of death – what was the cause of death How many brothers and sisters you have? They are alright.
11
5. Personal and social history
Ask about job. Are you married? How many children do you have? Their age? They are fine? Ask about, smoker/not, travel, pet, animal contact, any medicine he’s taking and allergy If patient is old – ask about where he lives e.g. ground floor or upstairs Any difficulties regarding toilet, cooking, shopping?
12
Usual Sequence of Events in Patient Care
History Examination – General Examination – Systemic Examination Problem list Differential diagnosis and most likely diagnosis Investigations Diagnosis confirmed Treatment
13
General Examination
14
General Examination General Examination includes - General appearance
- Alertness, mood, general behavior - Hands and nails - Radial pulse and blood pressure - Lymph node – axillary, cervical - Face, eyes, tongue - Peripheral oedema
15
General Examination General appearance Does the patient look ill ?
Alert, confused, drowsy Co-operative, happy, sad Obese, muscular, wasted In pain or distressed
16
General Examination Hands and nails Hands
Unduly cold, warm, cold and sweaty (anxiety, sympathetic over activity) Peripheral cyanosis Nicotine staining Raynaud’s Palms – palmer Erythema occurs with chronic liver disease, pregnancy Dupuytren’s contracture – thickened palmer skin to the flexor tendons of fingers (fourth finger)
17
General Examination Nails Clubbing
The tissue at the base of nail are thickened The angle between the base of nail and adjacent skin of finger is lost Nails become convex both transversely and longitudinally Causes - heart – infective endocarditis - lung – carcinoma bronchus, Bronchiectasis, fibrosing alveolitis - liver cirrhosis - Crohn’s disease
18
General Examination Nails (Cont)
Koilonychia – Concave nail (iron deficiency anemia) Leukonychia – white nails (cirrhosis liver) Splinter hemorrhages - Infective endocarditis Pitting – psoriasis Onycholysis – separation of nail from nail bed Psoriasis, Throtoxicosis
19
Finger clubbing
20
Koilonychia – spoon shaped nail from iron deficiency
21
Leuconychia
22
Splinter Hemorrhage in fingernails in bacterial endocarditis
23
Pitting of nails in Psoriasis
24
Dupuytren’s contracture- association Diabtes
25
General Examination Face, eyes, tongue
Mouth – look at the tongue moist or dry - Cyanosed (central) Central cyanosis – blue tongue Cause: - Congenital heart disease e.g. fallot’s tetralogy - Lung disease e.g. obstructive airway disease Peripheral cyanosis – blue fingers denotes inadequate peripheral circulation, tongue will be pink
26
General Examination Face, eyes, tongue (cont) Mouth
Look at the teeth – dental hygiene, caries Look at the gums – bleeding, swollen Smell patient’s breath - Ketosis – diabetes (sweet smelling breath) - Foetor – hepatic failure (musty smell) - Alcohol
27
General Examination Face, eyes, tongue (cont) Eyes
Look at the sclera – for jaundice (yellow sclera) Look at lower lid conjunctiva – anemia (pale, mucous membrane of conjunctiva) Eye lid – yellow deposit (Xanthelasma) Puffy eyelid e.g. general oedema (Nephrotic syndrome) , thyroid eye disease (myxoedema)
28
General Examination Eyes (cont)
Red eye – Iritis, conjunctivitis, episcleritis White line around cornea, Arcus senilis – suggest hyperlipidaemia in younger patient, but has little significance in elderly White band keratopathy – hypercalcaemia - Sarcoid - Parathyroid – hyperplasia - Lung oat – cell tumor - Vitamin D excess intake
29
Central Cyanosis of tongue
30
Peripheral Cyanosis hand and feet
31
Jaundice
32
Puffy eyes
33
Xanthelasma (cholestrol deposits)
34
Arcus senilis
35
Kayser Fleischer rings (Copper deposition in Wilson’s disease)
36
Myopathic face
37
Severe pitting edema of the legs
38
(Sarcoidosis, Inflammatory Bowel Disease)
Erythema nodosum (Sarcoidosis, Inflammatory Bowel Disease)
39
(Inflammatory Bowel Disease – Crohn’s and Ulcerative Colitis)
Pyoderma gangrenosum (Inflammatory Bowel Disease – Crohn’s and Ulcerative Colitis)
40
In the end (after taking history and examination), ask him, Have you any questions.
Please remember to cover the patient and THANK him/ her at the end of examination. Note : After history you should have ideas which system you wish to concentrate for examination. And after examination, you should put diagnosis/differential diagnosis
41
Thank you
Similar presentations
© 2024 SlidePlayer.com Inc.
All rights reserved.