HISTORY TAKING & GENERAL EXAMINATION By Dr. Zahoor

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

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

Importance of History Ask principal symptoms and allow the patient to describe Inquire about the sequence of symptoms and events Don’t ask leading questions in the beginning

Usual Sequence of History 1. 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

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 Obtain detailed description of each symptom

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

Example 1 Chest pain – 2 months Ask Site of pain Character – feeling pressure, dull, stabbing, shooting Radiation

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

Example 2 If patient c/o cough with sputum – 10 days Ask 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

3. Past history Ask for Previous illness, hospital admission Any operations (if yes, when it was done and what was the problem) Medicines

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.

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?

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

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

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

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

General Examination

General Examination General 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

General Examination General appearance Does the patient look ill ? Alert, confused, drowsy Co-operative, happy, sad Obese, muscular, wasted In pain or distressed

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 may be normal, also occurs with chronic liver disease, pregnancy Dupuytren’s contracture – thickened palmer skin to the flexor tendons of fingers (fourth finger)

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

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

Finger clubbing

Koilonychia – spoon shaped nail from iron deficiency

Leuconychia

Splinter Hemorrhage in fingernails in bacterial endocarditis

Pitting of nails in Psoriasis

Dupuytren’s contracture- association Diabtes

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

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

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)

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

Central Cyanosis of tongue

Peripheral Cyanosis hand and feet

Jaundice

Puffy eyes

Xanthelasma (cholestrol deposits)

Arcus senilis

Kayser Fleischer rings (Copper deposition in Wilson’s disease)

Myopathic face

Severe pitting edema of the legs

(Sarcoidosis, Inflammatory Bowel Disease) Erythema nodosum (Sarcoidosis, Inflammatory Bowel Disease)

(Inflammatory Bowel Disease – Crohn’s and Ulcerative Colitis) Pyoderma gangrenosum (Inflammatory Bowel Disease – Crohn’s and Ulcerative Colitis)

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

Thank you