HISTORY TAKING & GENERAL EXAMINATION - PowerPoint Presentation

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HISTORY TAKING & GENERAL EXAMINATION

By Dr. Zahoor

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History TakingImportant Points

Look confidentWelcome the patient saying Asalam O Alaikum

Shake hand with patient

Introduce yourself – I am so and so medical student

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Important PointsExplain that you wish to ask some questions to find out what happened

Make sure patient is comfortable and curtains are in placeConfirm patient’s name, age, occupation

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Importance of HistoryAsk principal symptoms and allow the patient to describe

Inquire about the sequence of symptoms and eventsDon’t ask leading questions in the beginning

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Usual Sequence of History

1. Chief complaint with duration2. History of present illness3. 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

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1. Chief complaint with duration

Patient c/o chest pain – 2 months2. History of present illnessAsk when he was completely well? Then what happened and then describe symptoms in chronological order of onset

Obtain detailed description of each symptom

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2. History of Present Illness

With all symptoms obtain details eg if pain - Duration

- One set – acute or gradual

- Constant or periodic - Frequency, radiation

- Precipitating or relieving factors

- Associated symptoms

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Example 1Chest pain – 2 months

Ask Site of pain

Character – feeling pressure, dull, stabbing, shooting

Radiation

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Example 1 (cont)

Severity – interfere with work or sleep

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

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Example 2If patient c/o

cough with sputum – 10 daysAsk about cough When he was well, how it started

When do you have cough, how long it lasts

Can he sleep well

Precipitating factors, relieving factors

Sputum

Color, how much amount do you cough up, smell, any blood in the sputum

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3. Past historyAsk for

Previous illness, hospital admissionAny operations (if yes, when it was done and what was the problem)Medicines

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4. Family HistoryAsk about

Parents – father and mother are alright Any history of hypertension, diabetes mellitusIf history of death – what was the cause of death

How many brothers and sisters you have? They are alright.

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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?

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Specimen History

Date - _____Mr. Ahmed Age: 50 years, machine operator C/O severe chest pain – 2

hours

But gives H/O chest pain since 6 months

History of present illness Perfectly well until 6 months ago, began to notice central dull chest pain occasionally radiating to the jaw, coming when he walks about 1km, worse when going up hill and in cold weather, when he stops the pain goes away after 2mins

GTN sublingual relieved pain

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Specimen History

Last month, pain came on less exercise after 100 yards Today at 10am, while sitting at work, chest pain started suddenly. It was worse pain he had experienced. The pain was central crushing in nature radiating to the left arm and neck with feeling of nausea and sweating

The patient was rushed to hospital where he received IV Diamorphine and ECG was done which

showed ANTERIOR

MI and he was given IV Streptokinase

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Specimen History After history of present illness, you will take past history, family history, personal and social history

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Usual Sequence of Events in Patient Care

HistoryExamination – General Examination – Systemic Examination

Problem list

Differential diagnosis and most likely diagnosis

InvestigationsDiagnosis confirmed

Treatment

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General Examination

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General ExaminationGeneral Examination includes

- General appearance - Alertness, mood, general behavior - Hands and nails

- Radial pulse and blood pressure

- Lymph node –

Cervical , Axillary

- Face, eyes, tongue

- Peripheral oedema

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General Examination

General appearance Does the patient look ill ?Alert, confused, drowsyCo-operative, happy, sad

Obese, muscular, wasted

In pain or distressed

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General Examination

Hands and nailsHands Unduly cold, warm, cold and sweaty (anxiety, sympathetic over activity)

Peripheral cyanosis

Nicotine staining

Raynaud’s Palms – palmer Erythema

may be normal, also occurs with chronic liver disease, pregnancy

Dupuytren’s contracture – thickened palmer skin to the flexor tendons of fingers (fourth finger)

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General Examination

NailsClubbingThe 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

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General Examination

Nails (Cont)Koilonychia – Concave nail (iron deficiency anemia)Leukonychia – white nails (cirrhosis liver)

Splinter hemorrhages

- Infective endocarditis

Pitting – psoriasisOnycholysis – separation of nail from nail bed

Psoriasis, Throtoxicosis

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Finger clubbing

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Koilonychia – spoon shaped nail from iron deficiency

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Leuconychia

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Splinter Hemorrhage in fingernails in bacterial endocarditis

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Pitting of nails in Psoriasis

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Dupuytren’s

contracture- association

Diabtes

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General Examination

Face, eyes, tongueMouth – 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

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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

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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)

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General Examination

Eyes (cont)Red eye – Iritis, conjunctivitis, episcleritisWhite 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

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Central Cyanosis of tongue

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Peripheral Cyanosis hand and feet

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Jaundice

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Puffy eyes

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Xanthelasma (

cholestrol

deposits)

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Arcus senilis

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Kayser Fleischer rings

(Copper deposition in Wilson’s disease)

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Myopathic face

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Severe pitting edema of the legs

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Erythema nodosum

(Sarcoidosis, Inflammatory Bowel Disease)

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Pyoderma gangrenosum

(Inflammatory Bowel Disease

– Crohn’s and Ulcerative Colitis)

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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

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Thank you

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