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 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
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

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
Obtain detailed description of each symptom

7. 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

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

9. 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

10. 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

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

12. 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.

13. 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?

14. 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

15. 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

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

17. 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

18. General Examination

19. 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

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

21. 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)

22. 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

23. 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

24. Finger clubbing

25. Koilonychia – spoon shaped nail from iron deficiency

26. Leuconychia

27. Splinter Hemorrhage in fingernails in bacterial endocarditis

28. Pitting of nails in Psoriasis

29. Dupuytren’s contracture- association Diabtes

30. 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

31. 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

32. 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)

33. 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

34. Central Cyanosis of tongue

35. Peripheral Cyanosis
hand and feet

36. Jaundice

37. Puffy eyes

38. Xanthelasma (cholestrol deposits)

39. Arcus senilis

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

41. Myopathic face

42. Severe pitting edema of the legs

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

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

45. 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

46. Thank you