History Taking and General Pe

7/31/2019 History Taking and General Pe

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Obtaining an accurate history is the critical

in determining the of

a patient's problem.A large percentage of the time70%), you will

actually be able make a diagnosis based onthe history alone.


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The sense of what constitutes important datawill grow exponentially in future as youlearn about the pathophysiology of disease

You are already in possession of the tools

that will enable you to obtain a goodhistory.An ability to listen and ask common-sense

questions that help define the nature of aparticular problem.

A vast and sophisticated fund of knowledgenot needed to successfully interview apatient.


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When you approaches your patient , there are 3initial Objectives :

* Obtain Professional Rapport with patient & gain hisconfidence.

* Obtain all relevant information which allowassessment of his illness & provisional diagnosis

* Obtain general information regarding patient(Background , Social Situation and Problems )andthe assessment of the patient as a whole is of

utmost importance. One should Never approachthe patient with just a set series of rote questions


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Look the part of a Dr and put the patient at ease , beconfident & friendly .

Greet the patient, shake handState you name & explainLet the patient tell his story in his own words as

much as possible by conducting a conversationrather than an interrogation , do not interrupt toomuch & keeping the patients train of thought asmuch as possible .

Ovoid Pseudo medical Terms & Ovoid leading

QuestionsBe understanding , receptive , and matter of factwithout excessive over sympathy , rarely showreproach


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Introduce yourself.Note never forget patient namesCreate patient appropriately in a friendly relaxed way.Confidentiality and respect patient privacy.

Try to see things from patient point of view. Understand patientunderneath mental status, anxiety, irritation or depression. Alwaysexhibit neutral position.

Listening

Questioning: simple/clear/avoid medical terms/open, leading,interrupting, direct questions and summarizing.


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Chief complaintHistory of present illness( details

of current illness )Past medical history

Systemic enquiryFamily historyPast Medical History :Drug

history & Treatment historySocial history& Personal HistoryIn Female Obstetric &

Gynecologic history


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The main reason push the pt. to seek forvisiting a physician or for help

Usually a single symptoms, occasionally morethan one complaints eg: chest pain,

palpitation, shortness of breath, ankleswelling etcThe patient describe the problem in their

own words.It should be recorded in pts own words.What brings your here? How can I help you?

What seems to be the problem?


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.


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Chief complaint

History of present illness

Past medical history

Systemic enquiryFamily history

Past Medical History

Social history


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Elaborate on the chief complaint in detailAsk relevant associated symptoms

Have differential diagnosis in mind

Lead the conversation and thoughtsDecide and weight the importance of minor

complaints


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Avoid medical terminology and make use of adescriptive language that is familiar to them


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With all symptoms obtain :* Duration* Onset : Sudden or gradual* What has happen since :Constant or periodic

, Frequency , Getting worse or better* Precipitating or relieving factors* Associated symptoms


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osition/site

everity how it affects daily work/physical activities. Wakes him up

at night, cannot sleep/do any work.

elationship to anything or other bodily function/position.

adiation: where moved to

elieving or aggravating factors any activities or position

uality, nature, character burning sharp, stabbing, crushing; also

explain depth of pain superficial or deep.

iming mode of onset (abrupt or gradual), progression

(continuous or intermittent if intermittent ask frequency andnature.)

reatment received or/and outcome.

nset of disease

Are there any associated symptoms? Check


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This is a guide not to miss anything

Any significant finding should be moved to HPCor PMH depending upon where you think itbelongs.

Do not forget to ask associated symptoms of PCwith the System involved

When giving verbal reports, say no significant

finding on systems review to show you did it.However when writing up patient notes, youshould record the systems review so that therelieving doctors know what system you

covered.


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Cough(productive/dry)Sputum (color, amount,smell)HaemoptysisChest painSOB/DyspnoeaTachypnoeaHoarseness

Wheezing

Chest pain

Paroxysmal Nocturnal DyspnoeaOrthopnoeaShort Of Breath(SOB)Cough/sputum (pinkish/frankblood)Swelling of ankle(SOA)

PalpitationsCyanosisAppetite (anorexia/weight

change)DietNausea/vomitingRegurgitation/heart

burn/flatulenceDifficulty in swallowingAbdominal pain/distensionChange of bowel habitHaematemesis, melaena,haematochagia

Jaundice

WeaknessFatigue

AnorexiaChange of weightFever FRCSLumpsNight sweats


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Frequency

DysuriaUrgencyHesitancyTerminal dribblingNocturiaBack/loin pain

IncontinenceCharacter of urine:color/amount (polyuria) & timingFever

Visual/Smell/Taste/Hearing/Speech problemHead acheFits/Faints/Black outs/loss of

consciousness(LOC)Muscleweakness/numbness/paralysisAbnormal sensationTremorChange of behaviour or psychePain/ discomfort/ itching

DischargeUnusual bleedingSexual historyMenstrual history menarche/LMP/ duration & amount of cycle/ContraceptionObstetric history Para/

Pain muscle, bone, jointSwellingWeakness/movementDeformitiesGait


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Start by asking the patient if they have any

IHD/HeartAttack/DM/Asthma/HT/RHD,TB/Jaundice/Fits

:E.g. if diabetic- mention time ofdiagnosis/current medication/clinic check up

E.g. time/place/ and what type of operation.Note any blood transfusion and blood grouping.

E.g. time/place/ and what type of accident


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Always use generic name or put trade name

in brackets with dosage, timing and howlong. Example: Ranitidine 150 mg BD PO

Note: do not forget to mention

OTC /Vitamins/Traditional medicine


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Current treatmentAllergy to drug

Abuse to drug

Other remedies( RT , CT , Immunotherapy &Hormonal )


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bd (Bis die) - Twice daily (usually morning andnight)

tds (ter die sumendus)/tid (ter in die) = Threetimes a day mainly 8 hourly

qds (quarter die sumendus)/qid (quarter in die) =four times daily mainly 6 hourly

Mane/(om omni mane) = morningNocte/(on omni nocte) = night

ac (ante cibum) = before foodpc (post cibum) = after foodpo (per orum/os) = by mouthstat statim = immediately as initial doseRx (recipe) = treat with


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Any familial disease/running in families e.g.breast cancer, IHD, DM, schizophrenia,Developmental delay, asthma, albinism

AFather

BMotherCEach siblingDHistory of disease in which heredity or

contact may play a role.

Rerecord a family tree


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Smoking history - amount, duration and type.A strong risk factor for IHD

Drinking history - amount, duration and type.Cause cardiomyopathy, vasodilatation

Occupation, social and education background,family social support and financial situation


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Gyane/Obstetric history if female

Immunization if small child

Note: Look for the child health card.

Travel and sexual history if suspected STI orinfectious disease

Note:

If small child, obtain the history from the caregiver. Make sure; talk to right care giver.

If some one does not talk to your language, getan interpreter(neutral not family friend ormember also familiar with both language). Asksimple & straight question but do not go for yes

or no answer.


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ubjective: how patient feels/thinks about him.

How does he look. Includes PC and generalappearance/condition of patient

bjective relevant points of patientcomplaints/vital sings, physicalexamination/daily weight,fluid

balance,diet/laboratory investigation andinterpretation

lan about management, treatment, further

investigation, follow up and rehabilitation

ssessment address each active problem aftermaking a problem list. Make differentialdiagnosis.


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Inspection

Palpation

Percussion

Auscultation


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Stethoscope

BP cuff

Otoscope Ophthalmoscope

Can you think ofany other tools?


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Vital Signs Pulse

Ventilations (Respirations)

Blood Pressure

Temperature Height

Weight

Spo2


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General Survey Mental Status

Emotional Status

Vital Signs Hand

Face

Neck

Chest

Abdomen Pelvis (as needed)

Posterior Body

Extremities Vascular

Musculoskeletal

Neurologic Exam


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What does mental status tell you about thepatient?


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What should welook for? Why?

What do thesethings tell us?


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Appearance &Behavior Posture & Motor

Activity

Dress, Grooming &Personal Hygiene

Facial Expression

Speech & Language

Mood

Thoughts &

Perceptions

Insight & Judgment

Memory & Attention


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General Physical Appearance Height, Weight & Build

Sexual & Physical Development

Posture, Gait & Motor Activity

Hair, Nails & Skin appearance Dress, Grooming & Personal Hygiene

Odors

Facial Expressions & Body Language


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Agitation

Apathy

Lack of expression Emotional laiblelity

Euphoria

cheerfullens


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Palpates scalp:11. Palpates thoroughly (temples, including

over temporal arteries), parietal sidesabove ears, crown, occipital back, palpate

temporomandibular joint as patient opensand closes jaw


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chevosteks sign

Jaw Jerk


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Inspect Visual acuity

Extraoccular movements, accommodation

Visual fields

Pupillary response, swinging flashlight

Fundoscopic exam


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Inspects external ocular (eye)structures (lids, conjunctiva, iris cornea,pupils)

13. Gently moves eyelids up and down to obtain

better view14. Checks acuity with Snellen and from properdistance (12-14 inches and any printedmaterial is acceptable)

15. Checks acuity both eyes separately


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16. Evaluates extraocular movement (big )17. Checks convergence and accommodation

(follows finger from far to near)

Six Cardinal Positions of Gaze

Need our picture

Convergence and

Accommodation

Needs illustration


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18.Visual fields - both eyes independently19. Visual fields - eight cardinal directions for

each eye (N,NE, E, SE, S, SW, W NW)

20. Visual fields - simultaneous stimulation(each eye should only be able to see onhand the one on that side)

21. Visual Fields Examiners hands or object

to view introduced in the plane half-waybetween patient and examiner


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Swinging Flashlight Test


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22. Pupillary response to light direct (sameeye the light is directed into)

23. Pupillary response indirect (eye light is notdirected into)

24. Swinging flashlight test (start in one eye,quickly move to other eye, wait then fastback to original eye and wait)


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: Inspects externally bilaterally(including behind ears)37. Palpates auricles bilaterally38. Otoscopic examination bilaterally39. Otoscopic examination performed without

pain40. Auricles pulled superiorly, posteriorly, andaway from patient

41. Auditory acuity tested (eyes closed iffinger rub and you can see movement of

hands or arm)42. Auditory acuity tested correctly (each earindependently, etc.)


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Nasal Speculum Palpate sinuses


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Look everywhere Say ah


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Should use light source forinspection

49. Inspect lips, gums, buccal mucosa, teeth

50. Inspect tongue, posterior pharynx

51. Inspect floor of mouth (under tongue)

52. Elevation of palate ("ah")

52. Examination done with minimal discomfort


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Inspect Carotids: palpate, auscultate (2)

Thyroid: isthmus and both lobes

10 lymph node areas


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Inspects anterior neck for symmetry55.Carotid arteries palpated

56.Carotid arteries correctly palpated, singly, (lower third of neck), fingers or t57.Auscultation of carotid arteries (lower carotids bilaterally)58.Auscultation of carotid arteries (upper carotids bilaterally)59.Thyroid gland palpated: Palpation from behind, chin is slightly extended(can palpate from front)60.Hands in proper position (below the cricoid cartilage)

61.Palpates the isthmus and has patient swallow62.Palpates the lobes and has patient swallow

Periauricular (in front of the ear)64.65.Posterior auricular (behind the ear)66.Occipital (base of skull)67.Tonsillar (angle of jaw)

68.Submaxillary (mid-jaw)69.Submental (under chin)70.Posterior cervical (back of neck)71. Superficial cervical (on top of the sternomastoid muscle)72. Deep cervical (deep in the sternomastoid muscle)73. Supraclavicular


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percussive auscultation

What else ?


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1) Ask the patient to lie supine.

2) Ask the patient to lower his gown to waistlevel.

3) Stand at the feet of patient.4) Inspect the shape of the chest (ratio of

antero-posterior and transverse diameters).

5) Inspect the symmetry of the patients chest

on both sides with comparison.


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Pectus carinatum Pectus excavatum


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6) Inspect patients chest normal breathingmovement.7) Inspect patients chest for accessory muscle

use.

8) Inspect patients chest for retraction oflower intercostal spaces.9) Stand again to the right of patient and look

tangentially for apical and epigastricpulsation.

10) Inspect the chest wall and skin for swelling,scars, skin eruption or engorged veins.


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1) Stand to the right of the patient.2) Ask the patient to lie supine.

3) Palpate upper lung zone to confirm the movement byplacing the palms in the infraclavicular fossa and thetwo thumbs in the midline at the level of suprasternal

notch. Let the patient inspire deeply and let yourthumbs follow chest movement.

4) Palpate middle lung zone by putting the palm in themiddle part with tips of thumbs in the midline. Let thepatient inspire deeply and let your thumbs follow chestmovement.


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5) Palpate lower lung zone by putting the palm in thelower part with tips of thumbs in the midline. Let thepatient inspire deeply and let your thumbs to followchest movement.

6) Palpate for palpable rhonchi, pleural rub or chest walltenderness by putting the palm on various areas ofchest wall.

7) Palpate for Tactile vocal fremitus

a) Place the palm of hand over various area of chest wall

in the direction of bronchial tree away from midlinewith comparison.

b) Ask the patient to repeat the words 99


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Increased TVF Decreased TVF

Consolidation

CavitationCollapse with patent mainbronchus

Thick chest wall

Pleural effusionPleural fibrosis

Pneumothorax

Emphysema

Collapse


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a) Stand to the right of the patient.b) Ask the patient to sit up with the head straight.c) Inspect for tracheal position Trills sign.d) Tracheal shift: Insert the index finger in horizontal

position in the pouch between the medial end ofsternomastoid and the lateral aspect of trachea with

comparison.e) Check the cricosternal distances. This is the distance

between the cricoid cartilage and the suprasternal notch.If it is less than 3 finger breadths, this indicateshyperinflation of the lung.

f) Tracheal descent: place the tip of the index finger onthe thyroid cartilage during inspiration to observe itsdescent.


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1- Stand to the right of the patient.2- Ask the patient to lie supine.3- Use light percussion.4- Krnigs isthmus: Percuss both areas right and left from

dullness to resonance (start from the neck) with comparison.5- Percuss both clavicles directly (over medial third)

6- Percuss the infraclavicular regions.7- Percuss both parasternal lines right and left, from thesecond space to the sixth space with comparison.

8- Spare bare area to be percussed late with special areaspercussion.

9- Percuss both midclavicular lines right and left, from the

second space to the sixth space with comparison.10-Comment on dullness found.


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1-Stand to the right of the patient.2-Ask the patient to lie supine and raise his hands above

his head.3-Use light percussion.4-Percuss both anterior axillary lines right and left, from

the fourth space to the eighth space with comparison.5-Percuss both middle axillary lines right and left, from

the fourth space to the eighth space with comparison.6-Percuss both posterior axillary lines right and left, from

the fourth space to the eighth space with comparison.

7-Comment on dullness found.


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1- Stand to the right of the patient.2- Ask the patient to lie supine.

3- Use heavy percussion.

4- Start in the right midclavicular line from

second space down to the first dullness.5- Decide the upper border of the liver.


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1- Stand to the right of the patient.2- Ask the patient to lie supine and raise his hands above

his head.3- Use light percussion.4- Percuss both anterior axillary lines right and left, from

the fourth space to the eighth space with comparison.5- Percuss both middle axillary lines right and left, from

the fourth space to the eighth space with comparison.6- Percuss both posterior axillary lines right and left,

from the fourth space to the eighth space with

comparison.7- Comment on dullness found.


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1- Stand to the right of the patient.2- Ask the patient to sit and stand behind him.

3- Use light percussion.

4- Percuss both areas right and left from

dullness to resonance with comparison.5- Comment on dullness found.


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1) Stand to the right of the patient

2) Ask the patient to lie supine.

3) Auscultate both midclavicular lines right &

left, from the second space to the sixth spacewith comparison.

4) Ask the patient to say 99 and auscultateboth midclavicular lines right & left, from thesecond space to the sixth space withcomparison


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1) Auscultate both midaxillary lines right & left, from the fourth

space to the eighth space with comparison2) Ask the patient to say 99 and auscultate both midaxillary

lines right & left, from the fourth space to the eighth spacewith comparison

Comment on :a) Breath sounds (character, intensity)b) Adventitious sounds (wheeze, crepitations)c) Type of wheeze if present ( inspiratory or expiratory,

localized or generalized )d) Type of crepitations if present (fine or coarse, change with

cough)e) Vocal resonance


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1) Stand behind the patient in a midlineposition.2) The patient should be sitting with the

posterior thorax exposed.

3) Inspect the cervical, thoracic and upperlumbar spine for deformity.4) Assess for costovertebral tenderness by

placing the ball of one hand in thecostovertebral angle and strike it with theulnar surface of your fist

5) Inspect for scars.


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1) Stand behind the patient in a midlineposition.2) The patient should be sitting with the

posterior thorax exposed.3) Assess extent and symmetry of lower

thoracic expansion bya) Place your thumbs at the level of the 10th ribs with

your fingers loosely grasping the rib cage and gentlyslide them medially.

b) Ask the patient to inhale deeply and observe whetheryour thumbs move apart symmetrically.

4) With palms of hands, assess symmetry offremitus throughout lung fields.


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A. B.


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1) Stand to the right of the patient.2) Ask the patient to sit and his hands foldedacross the anterior chest wall

3) Auscultate both scapular lines right & left,

from the apex to the tenth space withcomparison.4) Ask the patient to say 44 and auscultate

both scapular lines right & left, from the apexto the tenth space.


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Pleural effusion reduced tactile vocal

fremitus

reduced chestexpansion

stony dull

reduced air entry

no added sounds

reduced vocal

resonance

Consolidation increased tactile vocal

fremitus

reduced expansion

dull percussion

bronchial breathing

coarse creps

increased vocalresonance

whispering pectoriloquy


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Pneumothorax deviated trachea

reduced tactile vocalfremitus

hyper-resonance reduced air entry

reduced vocalresonance

Collapse deviated trachea

reduced tactile vocalfremitus

dull percussion reduced air entry

+/- creps


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prolonged expiratory phase (E > I)

indicates airway narrowing, as in:

Bronchial asthma.

Chronic bronchitis


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Jugular venous pulsation Inspection

Palpation

Auscultation

Special maneuvers


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Jugular venous pulsation Inspection Palpation

Valve areas PMI

Left lateral decubitus

Auscultation Diaphragm Bell

Tricuspid, mitral

Special maneuvers

Left lateral decubitus, apex, bell Sit up, lean, LLSB, exhale, diaphragm


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Inspection jugular vein (remember can be done at 0 15 30


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Inspection jugular vein (remember can be done at 0, 15, 30 ,will likely move table position)

104. Inspection done correctly; right side, head tilted left, patient elevated105. Inspection, palpation and auscultation for rest of cardiac examination

performed at 30 degrees106.Inspection of all 4 areas107.Palpation of aortic area (right second intercostal space just lateral to

sternum)108. Palpation of pulmonic area (left second intercostal space just lateral to

sternum)109.Palpation of right ventricular area (left lower sternal border)110.Palpation of apical area (about fifth intercostal space mid-clavicular line)

111.If apical impulse not palpable, patient in left lateral decubitus112.Palpation done with fingerpads in all 4 areas113.Auscultation with Diaphragm Aortic area114.Auscultation with Diaphragm Pulmonic area115.Auscultation with Diaphragm Tricuspid area (left lower sternal border)116.Auscultation with Diaphragm Mitral area (apical area)117.Auscultation with Diaphragm Sitting, left lower sternal border, patient fully

exhaled118.Auscultation with bell. Tricuspid area119.Auscultation with bell. Mitral area120.Auscultation with bell. Mitral area in the left lateral decubitus position121.Done correctly - Bell applied light pressure, not heavy (remember newer

stethoscopes diaphragm lightly OK)122Other. Stethoscope placed in examiner's ears correctly


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Inspection Auscultation

Percussion

Palpation


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Inspection

Auscultation

Percussion All 4 quadrants

Liver span

Palpation All 4 quadrants Liver Spleen

Right lateral ducubitus

Kidneys Aorta


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Palpate R Kidney Palpate L Kidney


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Inspection with adequate exposure (lower chest to pelvis)


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Inspection with adequate exposure (lower chest to pelvis)124. Auscultation: Listens at least 10 secs. (one place or can move to several

areas, must listen for at least 10 secs)125. Percussion: L abdomen above below umbilicus

126.Percussion: R abdomen above below umbilicus127. Percussion: Liver span (measure liver span, may do scratch test)128. Palpation: Lightly, all 4 quadrants129.Palpation: Deeply, all 4 quadrants130. Palpation: Liver (attempts to do)131. Palpation: Liver (correctly palpating deepest full inspiration, 1 hand under

one hand palpating or 2 palpating)

132. Palpation: Spleen (attempts to do)133. Palpation: Spleen (correctly - position, breaths, palpating deepest fullinspiration, 1 hand under L side, 1 feeling)

134. Palpation: Spleen (if not palpable, R lateral decubitus)135. Palpation: R kidney (take a deep breath, capture kidney, exhale, slowly

release kidney136. Palpation: L kidney (take a deep breath, capture kidney, exhale, slowly

release kidney)

137. Palpation: For abdominal aorta (to feel both the left and right walls of theaorta)138. Palpation: Inspects patients face during palpation (at least 50% of the time) 139. In correct order: Inspection, auscultation, percussion and palpation140. Abdominal Examination was done at 0.


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DR. TAREK NASSAR MRCP. MMED.MBBCH

History Taking and General Pe

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Transcript of History Taking and General Pe