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