1. By Dr. Zahoor 1

2.  Look confident  Welcome the patient saying Asalam O Alaikum  Shake hand with patient  Introduce yourself – I am so and so medical student 2

3.  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 3

4.  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 4

5. 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 5

6.  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 6

7.  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 7

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

9.  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 9

10.  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 10

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

12. 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. 12

13.  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? 13

14. Date - _____  Mr. Ahmed  Age: 50 years, machine operator  C/O severe chest pain – 2 hours 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 14

15.  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 MI and he was given IV Streptokinase 15

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

17.  History  Examination – General Examination – Systemic Examination  Problem list  Differential diagnosis and most likely diagnosis  Investigations  Diagnosis confirmed  Treatment 17

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19.  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 19

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

21. 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) 21

22. 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 22

23. 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 23

24. 24 Finger clubbing

25. 25 Koilonychia – spoon shaped nail from iron deficiency

26. 26 Leuconychia

27. 27 Splinter Hemorrhage in fingernails in bacterial endocarditis

28. 28 Pitting of nails in Psoriasis

29. 29 Dupuytren’s contracture- association Diabtes

30. 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 30

31. 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 31

32. 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) 32

33. 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 33

34. 34 Central Cyanosis of tongue

35. 35 Peripheral Cyanosis hand and feet

36. 36 Jaundice

37. 37 Puffy eyes

38. 38 Xanthelasma (cholestrol deposits)

39. 39 Arcus senilis

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

41. 41 Myopathic face

42. 42 Severe pitting edema of the legs

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

44. 44 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 45

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