history taking & general examination.pptx

history taking & general examination for MBBS students

1. History taking D r. Alpa Shaikh

2. What is History taking ? ▶ It is a process by which information is gained by a physician by asking specific questions to the patient with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient

3. Importance of History Taking ? Obtaining an accurate history is the critical first step in determining the etiology of a patient's illness. Diagnosis in medicine is based on Clinical history Physical Examination Investigations

4. A large percentage of the time (70%), you will actually be able make a diagnosis based on the history alone.

5. How to take a history ? “ Al w ay s listen to the patient they might be telling you the diagnosis” (Sir William Osler 1849 - 1919) The basis of a true history is good communication between doctor and patient. It takes practice, patience, understanding and concentration.

6. ▶ Introduce your self and create a rapport Approach to history taking

7. ▶ Be alert and pay full attention Approach to history taking

8. Ensure consent has been gained. Maintain privacy and dignity. Ensure the patient is as comfortable as possible The room should be comfortable, with adequate natural daylight because artificial light can affect skin color. Summarise each stage of the history taking process. Involve the patient in the history taking process If the patient is a female, a female attendant/nurse or a relative should be present. This is to protect the doctor from later accusation of improper conduct. Approach to history taking

9. Components of History taking Patient’s profile Chief complaint History of the present illness Past medical history Family history Socioeconomic history

10. 1. Patients profile Name – identity, documentation, speech Age – age related diseases Sex – sex related diseases Height, Weight – Nutrition related, endocrinal diseases Religion Occupation – occupation related diseases Address – socio economic status, financial status

11. Name – Establishes Identity and Ensures Accurate Documentation Fosters Trust and Rapport - Addressing patients by their names demonstrates respect and personalizes the interaction. Respects Cultural and Personal Identity - Correctly pronouncing and using a patient's name acknowledges their cultural and personal identity. Common disorders prevalent in certain Indian communities like β-Thalassemia. Communities with higher prevalence include: Sindhis, Punjabis & Gujarati Bhanushalis.

12. Age related diseases Chickenpox (Varicella) : Common in children , especially in temperate regions. Mental Health Disorders : Conditions like depression and anxiety are prevalent among adolescents. Bone Sarcomas : Osteosarcoma and Ewing sarcoma are most common in teens , often causing bone pain and swelling. Hodgkin Lymphoma : A common cancer in adolescents , presenting with swollen lymph nodes, fever, and weight loss. Type 1 Diabetes : An autoimmune condition where the immune system attacks insulin-producing cells in the pancreas, often diagnosed in adolescence. Systemic Lupus Erythematosus (SLE) : More prevalent in women aged 15–44 , affecting multiple organ systems. Multiple Sclerosis (MS) : Often diagnosed between ages 20 and 40 , leading to neurological symptoms.

13. Sex related diseases Autism Spectrum Disorders – ~4 times more common in males. Attention Deficit Hyperactivity Disorder (ADHD) – More common in boys, especially in childhood. Parkinson’s Disease – Men are about 1.5 times more likely to develop it. Migraines : Women are three times more likely to suffer from migraines, often linked to hormonal fluctuations. Coronary Artery Disease (CAD) – More common and often more severe in males, especially before age 60. Myocardial Infarction (Heart Attack) – Incidence is higher in men, partly due to protective effects of estrogen in premenopausal women. Hemophilia A and B – X-linked recessive; almost exclusively affects males. Duchenne Muscular Dystrophy (DMD) – X-linked, typically only seen in boys. Iron deficiency anemia: Approximately 45% of Indian women have been affected by anemia Osteoporosis : Post-menopausal women are at a significantly higher risk due to decreased estrogen levels, leading to reduced bone density. Thyroid Disorders : Women are 5 to 8 times more likely to develop thyroid issues, such as hypothyroidism and hyperthyroidism Urinary Tract Infections (UTIs) : Due to anatomical differences, women are more susceptible to UTIs Breast Cancer : While rare in men, breast cancer is the most common cancer among women

14. Height, Weight Nutrition-Related Diseases: Kwashiorkor and Marasmus:  Severe protein-energy malnutrition in children Tuberculosis (TB) : O ften associated with weight loss, which can be a significant symptom Diabetes: When the body cannot use insulin properly or doesn't produce enough, it can lead to weight loss as the body burns muscle and fat for energy.  Hypothyroidism/hyperthyroidism: An overactive thyroid gland speeds up metabolism, leading to weight loss.  (Addison's Disease):  This condition causes low cortisol levels, which can lead to fatigue, weight loss, and other symptoms.  Cushing's Syndrome: While Cushing's syndrome is often associated with weight gain. Cancer: Some types of cancer, particularly in the digestive tract, can cause weight loss . 

15. Religion Sickle Cell Anemia : This hereditary blood disorder is more common in certain regions and communities, including Scheduled Tribes and some Muslim populations, particularly in central India. Alcohol related disorders – less common in Muslim population due to teetotalism ( Abstaining from alcohol ) Human papilloma virus - Studies suggest a lower prevalence of HPV infection in women who are partners of circumcised men compared to those with uncircumcised men in India – seen in Muslim & Jewish population. Food habits - Vegetarian diets are often associated with lower risks of several chronic diseases, including  cardiovascular disease, diabetes, and certain types of cancer . Strict vegetarian diets, especially vegan diets, can pose a risk of micronutrient deficiencies, such as vitamin B12. Some studies have also linked vegetarian diets to an increased risk of gallstone disease and higher oxalate excretion, which may increase the risk of kidney stones.

16. Occupation – Skin, pulmonary diseases, occupation related diseases Occupational lung diseases like silicosis, asbestosis & Ocuupational asthma Occupational skin diseases – Hairdressing, Catering, Healthcare, Printing, Metal machining, Motor vehicle repair or Construction. Hearing loss - Workers in industries such as construction, mining, and manufacturing are prone to hearing loss. Infectious diseases – common in healthcare workers caused by repeated exposure to infectious workplace agents. Surgeons, teachers, and traffic police personnel are prone to varicose veins due to prolonged standing

17. Address – socio economic status, financial status Individuals in lower-income areas may be exposed to higher levels of pollution and other environmental hazards  Low socio economic status can be associated with increased prevalence of unhealthy behaviors like smoking, alcohol, poor diet, and lack of physical activity Tuberculosis: factors like poverty, crowded living conditions, and inadequate healthcare contribute to the spread of tuberculosis. Malaria, dengue, vector borne diseases: Malaria is a significant health concern in low-income areas. Diarrhea, cholera, water borne diseases: Poor sanitation, lack of access to clean water and hygiene

18. 2. Chief complaint ▶ The main reason for which the patient is trying to seek medical help by visiting the physician. ▶ Usually a single symptom, occasionally more than one complaints eg: fever, headache, pain, etc ▶ The patient describe the problem in their own words. ▶ It should be recorded in patients own words. ▶ The complain should be recorded with their onset duration

19. ▶ How to ask for chief complaint? What brings your here? How can I help you? What seems to be the problem? ▶ If there is more than one complaint, it should be written according to chronological order All symptoms are not of equal diagnostic importance. 2. Chief complaint

20. 2. Chief complaint Example, ▶ Fever- 2 weeks ▶ Productive cough- 1 week ▶ Vomiting - 2 days ▶ Fatigue-1day

21. 3. History of the present illness ▶ Elaborate on the chief complaint in detail ▶ Ask relevant associated symptoms ▶ Gain as much information you can about the specific complaint. ▶ A sk questions. ▶ Always start with an open ended question and take the time to listen to the patient’s ‘story’ ▶ Once the patient has completed their narrative then closed questions can be asked to clarify . ▶ Leading question are to be avoided.

22. ▶ Open questions allow patients to express their own thoughts and feelings, e.g. 'Is there anything else that you want to mention?’ ▶ Closed questions are requests for factual information, e.g. 'When did this pain start?’ ▶ Leading questions are based on your own assumptions that lead the patient to the answer you want to hear. E.g. ‘ You didn't finish the course of antibiotics I prescribed, did you?’   rather than ‘Did you finish the course of antibiotics I prescribed?’ 3. History of the present illness

23. ▶ In details of present problem with- time of onset/ mode of evolution/ any investigation; treatment &outcome/any associated +’ve or - ’ve symptoms. ▶ Avoid medical terminology and make use of a descriptive language that is familiar to patients ▶ Sequential presentation ▶ Always relay story in days before admission ▶ Narrate in details 3. History of the present illness

24. 3. History of the present illness ▶ Tips to gather information: S O C R A T E S Site Onset Character Radiation (of pain or discomfort) Alleviating factors Timing Exacerbating factors Severity (

25. ▶ The patient was apparently well 1 week before the admission when the patient fell while gardening and cut his foot with a stone. By that evening, the foot became swollen and patient was unable to walk. Next day patient attended a private clinic where they gave him some oral medicines. The patient doesn’t know the name of the medicines given but says that he was told the medicine would suppress his leg pains. H owever There was no improvement in his condition. Two days prior to admission in AIIMS, Kalyani , the swelling in the foot started to discharge pus. There is high fever and rigors with nausea and vomiting. 3. History of the present illness

26. 4. Past medical history ▶ Any history of similar complaint in the past ▶ Other medical problems the patient has or had ▶ Any chronic disease present like hypertension, diabetes etc ▶ Past hospitalizations and past surgeries . ▶ Medications if any taken in the past (dosage and duration) ▶ Allergies ▶ Pediatric: Birth history, Developmental Milestones, Immunization history ▶ Obgyn history if female patient.

27. 5. Family history ▶ It is important to establish whether there are any genetically transmitted diseases within families ▶ Any illness run in the family? ▶ Similar history in the family ? ▶ Parents and siblings suffering with any chronic illness, ▶ Parents if died, at which age and what did they died of ? ▶ You should be able to collect relevant family history depending upon the present illness. ▶ Example, Patient has come due to anemia , Try to rule out sickle cell, thalasemia/ G6PD deficiency

28. 6. Personal history ▶ Smoking history - amount, duration , pack years and type. ▶ Drinking history - amount, duration and type . ▶ Any drug addiction ▶ Sexual history if suspected STI ▶ Bowel & bladder habits - frequency, consistency, and any accompanying symptoms like pain or blood ▶ Occupation, soci oeconomic and education background, financial situation

29. 7. System Review Cardiovascular Chest pain Paroxysmal Nocturnal Dyspnoea Orthopnoea Short Of Breath Cough/sputum Palpitations Cyanosis Respiratory System Cough(productive/dry) Sputum (colour, amount, smell) Haemoptysis Chest pain SOB/Dyspnoea Tachypnoea Hoarseness Wheezing General Weakness Fatigue Anorexia Change of weight Fever Lumps Night sweats Gastrointestinal/Alimentary Appetite (anorexia/weight change) Diet Nausea/vomiting Regurgitation/heart burn/flatulence Difficulty in swallowing Abdominal pain/distension Change of bowel habit Haematemesis, melaena Jaundice

30. Urinary System Frequency Dysuria Urgency Hesitancy Terminal dribbling Nocturia Back/loin pain Incontinence Character of urine:color/ amount (polyuria) & timing Fever Genital system Pain/ discomfort/ itching Discharge Unusual bleeding Nervous System Visual/Smell/Taste/Hearing/ Speech Head ache Fits/Faints/Black outs/loss of consciousness(LOC) Muscle weakness/ numbness/ paralysis Abnormal sensation Change of behaviour or mood Musculoskeletal System Pain – muscle, bone, joint Swelling Weakness/movement Deformities 7. System review

31. Now you’ve got your information ▶ Give a Summary ▶ Ask if you’ve understood the information correctly ▶ Ask if there is any other information that the patient wants you to know ▶ Advise what your plan would be ▶ Check with the patient that they are in agreement with your plan

32. General Physical Examination General appearance : Built, body proportion, nutrition D ecubitus Pallor Oedema Lymphadenopathy Icterus Cyanosis Clubbing Skin & appendages Pulse rate. Temperature. Blood pressure.

33. General appearance : 1. Built: Built is the skeletal structure in relation to age and sex of the individual as compared to a normal person. Tall Stature: A child is considered to be tall when the height is greater than 2 standard deviations above the mean for the age. Eg : primary gigantism, hyperpituitarism, Klinefelter’s, Marfan’s syndrome Short Stature (Dwarfism): Dwarfism is the term applied when the patient's height is 2standard deviations less than that for his/her age and sex eg : Genetic, Turner's syndrome (45XO), Down's syndrome, Malnutrition, hypopituitarism, hypothyroidism, hypopituitarism, hypothyroidism, Achondroplasia. 2. Body proportion : Normally, in adults, The upper segment (from vertex to the pubic symphysis) is equal to the lower segment (from pubic symphysis to the heel). [US>LS is seen in achondroplasia, cretinism and juvenile myxedema & US<LS is seen in eunuchoidism, Marfan's syndrome, homocystinuria, Klinefelter's syndrome 3. Nutrition : Certain clinical signs like rough skin, brittle hair ( Hypoproteinemia ), cachexia with hollowing of cheeks, loss of the shape of hips, flat abdomen and absent fat over the subcutaneous tissues of the elbows ( Fat malnutrition ), Iron deficiency causes koilonychia and pallor.

34. Decubitus - Posture a patient adopts when lying in bed Hemiplegia: The patient lies in bed with one side immobile, the affected arm flexed and the affected leg externally rotated and extended. Meningitis and tetanus: The patient has neck stiffness and opisthotonos. Colic: In renal, biliary or intestinal colic, the patient is markedly restless and tossing and turning in bed in agony. Pneumonia and pleurisy: The patient is most comfortable lying on the affected side Acute inflammatory abdominal disease: The patient lies on his back quietly with legs drawn up.

35. Pallor Pallor is paleness of skin and mucous membrane either as a result of diminished circulating red blood cells or diminished blood supply Causes I. Anemia : A. Hemorrhagic B. Hemolytic C. Dyshemopoietic 1. Deficiency ofiron , folic acid or Vitamin B 12, Aplastic anemia , Systemic and infiltrative diseases, Chronic infection, Pregnancy, Malignancies II. Vasoconstriction: A. Shock Hypovolemic / cardiogenic B. Exposure to cold C. Fright D. Syncope and postural hypotension E. Arterial Occlusion III.Cutaneous : A. Thick skin and nails B. Edema ( edema causing diseases) C. Myxedema

36. Sites where anemia is detected 1. Lower palpebral conjunctiva 2. Tongue 3. Soft palate 4. Palm and nails 5. Other mucosal areas like vaginal or rectal mucosa

37. Oedema Edema is the collection of fluid in the interstitial spaces or serous cavities. It becomes evident only when 5-6 liters of fluid has accumulated in the water depots. Pitting on pressure occurs when the circumference of the limb is increased by l 0%. Site - Venous edema commonly occurs in the lower limbs which are most dependent. However, if the patient is recumbent,. edema may be present only over the sacral region which is, then, most dependent.

38. Causes Bilateral: A. Cardiac: CCF, LVF, pericarditis B. Renal: Acute nephritis, nephrotic syndrome C. Hepatic: Cirrhosis of liver, portal hypertension D. Venous: Inferior vena cava obstruction E. Endocrine: Myxedema F. Allergic: Angioneurotic edema G. Nutritional: Anemia , hypoproteinemia , beriberi. H. Toxic: Epidemic dropsy Unilateral: A. Lymphatic: 1. Filariasis 2. Pressure by new growth, metastasis 3. Radiation B. Traumatic: Bruises, sprains, fractures C. Infections: Cellulitis, boils, carbuncle D. Metabolic: Gout E. Venous: Venous thrombosis, varicose veins. F. Hereditary: Milroy's disease

39. Lymphadenopathy Lymphadenopathy is inflammatory or non-inflammatory enlargement of lymph nodes. A physical exam involves palpating (feeling) the lymph nodes in various areas like the neck & armpits. The lymph nodes of the neck should be examined by standing behind the patient with the patient's neck slightly flexed. The nodes must be examined from above downward -submental, submandibular, tonsillar, cervical, posterior auricular & occipital groups

40. Causes I. Inflammatory A. Acute Lymphadenitis B. Chronic Lymphadenitis: 1. Septic, Tuberculosis, Syphilis, Filariasis, Lymphogranuloma inguinale, HIV with AIDS II. Neoplastic A. Primary: Lymphosarcoma B. Secondary: Carcinoma, sarcoma, malignant melanoma III. Hematological : A. Hodgkin's disease B. Non-Hodgkin's lymphoma C. Chronic lymphatic leukemia IV. Immunological: Serum sickness, drug reaction, SLE and rheumatoid arthritis

41. Icterus/ Jaundice is a symptom complex which is characterized by yellow coloration of tissues and body fluids due to an increase in bile pigments.

42. Cyanosis Cyanosis is a bluish discoloration of the nails due to increased amount of reduced hemoglobin (more than 5 mg%) in capillary blood. Types: I. Central II. Peripheral III. Cyanosis due to abnormal pigments IV. Mixed Site – Central cyanosis is seen earliest on the palate, tongue, inner sides of the lips. Peripheral cyanosis is visible on the tip of nose, ear lobule, tip of finger, nailbed and cheek.

43. Causes I. Central: A. Cardiac 1. Congenital, cyanotic heart disease: Fallot's tetrad, Eisenmenger's complex etc. 2. Congestive cardiac failure. B. Pulmonary 1. Chronic obstructive lung disease. 2. Collapse and fibrosis of lung. 3. Marked pulmonary destruction due to any cause. 4. Pulmonary AV fistula. C. Abdominal hepato-pulmonary syndrome. D. High altitude due to low partial pressure of oxygen. II. Peripheral: A. Cold (local vasoconstriction) B. Increased viscosity of blood C. Shock D. Reynaud's phenomenon III. Mixed A. Acute left ventricular failure B. Mitral stenosis (left atrial failure and peripheral vasoconstriction).

44. Clubbing Clubbing is bulbous enlargement of soft parts of the terminal phalanges with both transverse and longitudinal curving of the nails. Schamroth's Sign: Normally when two fingers are held together with nails facing each other, a diamond-shaped space is seen at the level of proximal nail fold. This is lost in case of clubbing.

45. Grades I. Softening of nail bed II. Obliteration of the angle of the nail bed Ill. Swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and wet and increasing the curvature of the nail, resulting in parrot beak or drumstick appearance IV. Swelling of the fingers in all dimensions associated with hypertrophic pulmonary osteoarthropathy causing pain and swelling of the hand, wrist etc.

46. Causes 1. Pulmonary a. Bronchogenic carcinoma, mesothelioma b. Lung abscess c. Bronchiectasis d. Tuberculosis with secondary infection e. Diffuse fibrosing alveolitis f. Empyema 2. Cardiac a. Infective endocarditis b. Cyanotic congenital heart diseases c. Atrial myxoma 3. Alimentary a. Ulcerative colitis b. Crohn's disease c. Cholangiolitic cirrhosis d. Biliary cirrhosis e. Hepato-pulmonary syndrome 4. Endocrine a. Myxedema b. Thyroid acropachy (thyroid nails of hyperthyroidism e.g. in Grave's disease) c. Acromegaly 5. Miscellaneous a. Hereditary b. Idiopathic

47. Skin & appendages 1. Color - pale, flushed, cyanosed, yellow 2. Pigmentation – endocrine, deficiency, infections, metabolic, neurofibramatosus 3. Hypopigmentation - leprosy, leukoderma, albinism, fungal infections of skin 4. Eruptions – macules, papules, pustules, nodules, vesicles, bullae. 5. Neurocutaneous Stigmata ( Phakomatoses ) - Cafe-Au-Lait spots seen in neurofibromatosis, tuberous sclerosis, Sturge weber syndrome. 6. Hemorrhage – purpura, hematoma 7. Types of Skin - dry skin, moist skin, thick skin, thin skin 8. Hair – falling of hair, Patchy hair loss, Loss of outer third of the eyebrow, Absence of axillary, pubic and facial hair, Excessive hair growth in women 9. Nails – Pallor, Koilonychia, Onychia, Discoloration

48. Body temperature The body temperature refers to the temperature of the viscera and tissues of the body. The body temperature is best recorded with a mercury thermometer, which should be kept in position for about a minute. Usually temperature is recorded in the axilla. However, if there is a lot of perspiration, oral temperature should be taken. In cholera, rectal temperature is recorded which may be high, whereas the skin temperature may be subnormal. The normal body temperature varies from 36°C -37.5°C. There is normally a diurnal variation of 1 ° c, the lowest temperature being between 2-4 am and highest in the afternoon.

49. Pulse rate Pulse is a wave which is felt by the finger, produced by cardiac systole travelling in the peripheral direction in the arterial tree at a rate faster than the column of blood. Pulse is assessed by: l. Rate (No. of beats/min) a. Tachycardia b. Bradycardia 2. Rhythm a. Regular b. Regularly irregular (e.g. second degree heart block 3:2, 4:3, Wenkeback ; Ventricular Bigemini or Trigemini). c. Irregularly irregular (e.g. atrial fibrillation, ventricular or atrial ectopics ) 3. Force, volume, tension 4. Equality 5. Peripheral pulses (e.g. femoral, posterior tibial, dorsalis pedis) 6. Radio-radial delay (pre-ductal coarctation of aorta), radio-femoral delay (post ductal coarctation of aorta) 7. Apex pulse deficit ( atrial fibrillation)

50. Blood pressure Systolic BP is controlled by the stroke volume of the heart and the stiffness of the arterial vessels. Diastolic BP is controlled by the peripheral resistance. The phases are: Phase I: The first appearance of faint clear tapping sounds (Thuds) which gradually increase in intensity. Phase II: The softening of the sounds which may become swishing or blowing. Phase III: The return of sharper softer sounds, which become crisper, but never fully regain the intensity of phase I sounds. Neither phase II nor phase III has any known clinical significance. Phase IV: Distinct abrupt muffling of sounds, which become soft and blowing. Phase V: The point at which all sounds disappear completely.