Dr. Dini Sri Damayanti,MKes

Clinical assesment

Taking together the history, information from the physical examination and any investigations or tests, this should provide all the information needed to make a diagnosis(i.e. to identify the nature of a health problem).

New clinical students often feel embarrassed about asking about a patient’s feelings,expectations or concerns. Ask about these aspects in the same, matter-of-fact way as you ask about other aspects of the history. If you feel comfortable asking the questions, the patient is more likely to feel comfortable about answering.

Providing structure to the consultation

1. Know what information you needhave the main headings of the history and lists of any systems-specific questions in front of you

2. Take notes take brief notes during the consultation itself

Building the relationship

1. Develop rapport• accept the patient’s views and feelings

non-judgementally• use empathy• be supportive• deal sensitively with embarrassing or

disturbing topics, and pain2. Involve the patient• share your thinking with the patient• explain the rationale for your questions• during physical examination, explain the

process and ask permission

3.Respond to the patient’s needs• e.g. if the patient seems in discomfort, or tired, or in pain, acknowledge this andrespond appropriately - do not simply continue.

4. Use appropriate non-verbal behaviour

• eye contact, facial expression, posture, position and move

vocal cues, e.g. rate, volume, tone

How to take a history

Start by putting the patient at ease:• Greet the patient by name: "Good morning, Mrs Jones"

• Introduce yourself and explain that you are a medical student.

• Shake the patient's hand, or if they are unwell rest your hand on theirs.

• Ensure that the patient is comfortable.

Standard history taking

• Name• Address• Date of birth• Date of admission• Presenting complaint• History of presenting complaint• Previous medical history• Systems enquiry• Drug history and allergy• Family history• Social history• Conclusion/summary

History of presenting complaint

If the history of the presenting complaint includes pain “SOCRATES”

• Site - where exactly is this pain?• Onset - when did the pain start, did it start

suddenly or gradually?• Character - describe the pain - sharp?

knife-like? gripping? vice-like? burning? crushing?

• Radiation - does the pain spread anywhere? To the arm, jaw, groinetc?

• Associations - is the pain accompanied by any other features?

• Timing - does the pain vary in intensity during the day?

• Exacerbating and relieving factors - does anything make the pain better or worse?

• Severity - does the pain interfere with daily activities or with sleep?

Questions to ask about previous medical

History General question:• Have you suffered from any previous illness?

Medical• Ask about childhood illness and immunization• Have you had TB or whooping cough?• Have you ever been found to have high blood

pressure?• Have you had rheumatic fever?• Have you ever suffered from epileptic seizures?• Do you get asthma (episodic breathlessness,

usually with wheeze)?• Have you suffered from anxiety or depression?• Do you have diabetes?

Surgical• Have you had any operations in the

past?Obstetric (where appropriate)• Have you had any pregnancies?• Were they normal?• Were there any complications such

as hypertension and toxaemia,diabetes, Caesarian section?

Questions to ask patients about their general health:

Cardiovascular and respiratory function• Do you have a cough?• Do you cough anything up?• Have you ever smoked? If so what, how

many, and for how long?• Do you get short of breath?• Do you wheeze?• Do you get any chest pain?• Do your ankles swell?

Gastrointestinal function Has there been any change in your appetite?

Has there been any change in your weight?• Have you suffered from nausea or vomiting?

Has there been any change in the character or frequency of your bowel movements?

Has there been any change in the colour or consistency of your stools?

Have you had any bleeding? - while vomiting (haematemesis) or melena

Genitourinary function How often do you pass urine? Do you have pain or burning on passing

urine? Do you have pain in the small of your back

(renal angles)? Is there any blood in your urine

(haematuria)? Do you have any sexual problems?

Specific questions for men• Do you have any penile discharge or venereal

infection?• Do you have any difficulty starting to pass

urine (hesitancy or urgency),maintaining the flow of urine (poor stream), or

stopping the flow of urine(terminal dribbling)?

Specific questions for women• Do you have any vaginal discharge?• When did your periods start?• Are your periods irregular?

• How often do your periods occur and for how long do they last?

• Do you have heavy bleeding (menorrhagia) or do you pass clots duringyour period?

• When did your periods stop (menopause)?• Have you had any bleeding since your

periods stopped?• How many children have you had and when

did you have them?• Did you have any complications during any

pregnancy?

Musculoskeletal function• Have you any weakness in your arms or legs?• Do you have any stiffness in your joints or

spine?• Do you have pain in your joints or spine?

Neurological function• Do you have any headaches?• Have you had any dizziness (feeling of

instability or rotation)?• Do you get ringing in your ears (tinnitus)?• Do you get abnormal sensations or tingling in

your hands or feet (paraesthesia)?

• Have you noticed changes in your sense of hearing, smell, taste,vision?

• Have you any incontinence of urine or stools?

• Do you get depressed?• Do you get anxious?

Drug history and allergies• What drugs, homoeopathic and

herbal medicines and/or health foods do you take? - and in what dose?

• What other therapies do you have? - Physiotherapy? Occupational therapy? Malaria prophylaxis?

• Do you have any allergies?• Have any medicines ever upset you?

Family history• Are your father, mother, brothers, sisters alive? - If they have died, at what age did he/she/they die? What did he/she/they die of?

• Do they have any current illnesses?

• Do any illnesses run in your family?

Social history• Who is at home with you?• Are you single, married, widowed or

divorced?• Is your partner healthy?• How many children have you got?• Are your children healthy?• What is your occupation?

• Do you have any financial worries?• Do you smoke? - If so, how may per

day/week?• Have you ever smoked? - Why did you

give up?• Do you drink alcohol? - If so, how many

units per day/week?• Have you been abroad? - If so, where?• Do you have pets?• If mobility is a problem: What is your

home like? Do you have to manage stairs? What facilities have you got?

Ending Consultation1. When you are satisfied that you

have completed the history-taking, tell the patient that you have covered everything that you need to.

2. Check that the patient has nothing more to add.

3. Summarise the information and check that it is complete and accurate.

4. Explain what will happen next (e.g. you will pass the information on to the doctor,whether they are going to be seen soon by the doctor etc.)

5. Thank the patient and leave immediately after concluding the interview.

General Tips on How to Perform an Examination

To begin the Examination• Wash your hands• Introduce yourself (full name and role)• Greet the patient with their title and surname, and check you are using their preferred form of address

• Explain what you would like to do and obtain consent for the examination

• Then position the patient appropriately (45 degrees for cardiovascular and

respiratory, flat for abdominal)• Then expose the relevant part of

the patient ensuring as much privacy as possible.

• Perform a general inspection from the end of the bed.

During the ExaminationHave a methodical approach to

examination. Although each system is slightly different thestandard order is:

• Inspect• Palpate• Percuss• Auscultate

PRINCIPLES OF THE PHYSICAL EXAMINATION

GENERAL SURVEY

Exam begins the minute you first see the patient

Exam continues throughout your patient interaction

WEALTH OF INFORMATION!!!!

OBSERVATION

STATURE

HEALTH STATUS

WEIGHT

PERSONAL HYGIENE

SKIN COLOR /LESIONS

BREATH/ODOR

MOOD/ATTITUDE

WHEN WE PERFORM A PHYSICAL EXAM WE USE

TECHNIQUES OF THE PHYSICAL EXAMINATION

VISUAL INSPECTION

PALPATION

PERCUSSION

AUSCULATION

VISUAL INSPECTION

INSPECT CAREFULLY ALL AREAS OF EXAM

DOCUMENT BOTH NORMAL AND ABNORMAL FINDINGS

PALPATION

PALPATIONTEXTURESIZECONSISTENCYCREPITUSMASSESEXAMPLE – TAKING A PULSE, HEAD AND

NECK EXAM

PERCUSSION

PERCUSSION

USE OF THE HANDS AND FINGERS

STRIKING ONE OBJECT AGAINST ANOTHER

AUSCULATION

AUSCULATION

LISTENING FOR SOUNDS PRODUCED BY THE BODY

BLOOD PRESSURE, INTESTINAL SOUNDS

To end the Examination1) Consider whether you need to examine any

system in more depth (e.g. a full examination ofjoints in a patient with rheumatoid arthritis).

2) Re-examine any aspect that you are unsure about.

3) Inform patient that you have completed your examination. Thank them and help them getdressed.

4) Wash hands once more.

After the consultation has finished and you have left the patient:

a) Write a two line summary of what you found in the history and examination

b) Offer a differential diagnosis list for the presenting complaint if the diagnosis has not been fully established.

c) Make a problem list which will include the present complaint, other illnesses and other personal, psychological or social factors which affect this illness.

d) Consider what tests (biochemical and radiological) are required to confirm or establish the diagnosis.

e) Consider what treatment should be given to the patient.f) Consider what/if arrangements are needed to hand over

the patient’s care to another team.f) Reflect how the consultation was performed including

points to consider for future

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