History taking and lhysical examination.pptx

PE

1. Physical Diagnosis Dr. Deni

2. Physical Diagnosis Is clinical assessment technique aimed at identifying health problems of a patient through careful history taking and systematic physical examination. It has two parts History taking Physical examination

3. History T aking Systematic collection of data in a manner that help to identify key health problem of a patient. It is not simply list of symptoms rather they are listed in a way to rule in or rule out a certain disease.

4. History taking Components of history taking include: Identification Chief complaint History of presenting illness Past medical history Review of system Personal and social history Family history

5. 1. Identification Include: F ull name ƒ Age Sex ƒ Address ƒ Marital status ƒ Ethnic origin ƒ Religion ƒ Occupationƒ Level of education of the patient.

6. Identification … Other issues to be included under identification: Sources of history Source of referral mode of arrival Previous admission

7. 2. Chief Complain These are the major symptoms for which the patient is seeking care or advice. They should be written using patients own word. The duration of the complaint should be specified. Eg . Cough of 2weeks duration Easy fatigability of 1 month duration

8. 3. History of Presenting Illness This section is a clear chronological account of the problems for which the patient is seeking care. Date of onset: It is usually start the phrase “the patient was relatively well until ….” Mode of onset, course and duration: Ask whether the onset was: ƒ abrupt or gradual ƒ intermittent or persistent ƒ short lived or constant, and ƒ steady or increasing in severity.

9. 3. HPI…. Character and Location: Eg . pain Stabbing ƒ, Burning ƒ Pricking ƒ , Aching Ask also about the location and radiation Epigastric pain Radiating to B ack, S houlder, Left arm

10. 3. HPI…. Aggravating and R elieving Factors Any factor that improve or worsen the symptom should be listed. Eg . Epigastric / periumbilical pain radiating to the back and slightly relieved on leaning forward. Left sided chest pain which worsen on leaning forward. Effect of Treatment Type of treatment given and its outcome.

11. 3. HPI…. Associated symptoms: List of symptoms occurred with the chief compliant. Eg . Abdominal pan: Frequent non projectile vomiting of ingested matter which latter become bilous , failure to pass feces and flatus and minimal abdominal distension. One episode of non projectile vomiting of ingested matter, anorexia, nausea and low grade persistent fever.

12. 3. HPI…. Negative- Positive statements: These inquiries are conducted as thoroughly as possible with a view to constructing a differential diagnosis. A negative statement is as important as a positive statement. Eg . Cough No Hx night sweating, Wt loss, anorexia and contact with known TB pt. No Hx of orthopnea, Paroxysmal nocturnal dyspnea and leg swelling.

13. 4. Past medical History This includes important illnesses Childhood illnesses like measles, mumpsƒ A dult hood diseases Accidents and injuries ƒ Operations. ƒ History of chronic illnesses like HTN, DM, epilepsy, TB, cadriac disease, asthma etc. ƒ History of blood transfusion

14. 5. Personal and Social History Early development : place of birth and where the patient lived before, childhood development, health and activities. Education: School history, achievements, and failures, Work Record: T ype of work and age begun, The income, number of jobs, Success or failure regarding shift of jobs, occupational hazards A ttitudes to work, employers and work mates.

15. 5. Personal and Social History Home surroundings: S anitary condition P ossible existence of over crowding or loneliness Habits: D ietary history; history of substances like alcohol, tobacco, chat, etc. One has to try to quantify the daily alcohol and tobacco consumption.

16. 6. Family History Father and Mother: list their ages and current health status (If dead, the date and possible cause of death should be mentioned) Familial Diseases : like T uberculosis, A sthma, D iabetes mellitus, Hypertensive, M igraine, malignancy etc

17. 7. Review of System General : This includes history of recent weight change, weakness, fatigue, fever, etc. H.E.E.N.T. (Head, Eye, Ear, Nose, Mouth and Throat) Head: Headache or injuries. Eyes: blurring of vision, itching, pain, redness, excessive tearing, eye discharge etc. Ear: hearing problem, earaches, discharge, etc. Nose: nasal discharge or itching, nasal bleeding, etc. Mouth and Throat: sore tongue, and hoarseness of voice, dry mouth, oral thrush, dental carries, etc.

18. 7. Review of System… Lympho -glandular system: Breast pain, discharge, swelling Cold/hot intolerance Anterior neck swelling ƒ Respiratory system: Cough Production of sputum Hemoptysis Dy s pnea Chest pain Cardiovascular system: Dyspnea Palpitation Orthopnea paroxysmal nocturnal dyspnea Cough Chest pain Syncope Swelling of the feet

19. 7. Review of System… Gastro intestinal system: Abdominal pain Difficulty of swallowing, heartburn, nausea, vomiting, abdominal pain, constipation, diarrhea, excessive belching rectal bleeding, tarry stool, and jaundice.

20. 7. Review of System… Genito – Urinary system: Urinary symptoms F lank pain, polyuria, N octuria , dysuria C hange in color of urine, urgency, frequency, hesitancy, dribbling, Genitals: Males: Groin swelling, Urethral Discharge testicular pain or undescended testicles, . Female Vaginal bleeding Vaginal discharge Absence of mensus D ysmenorrhea

21. 7. Review of System… Integumentary system: dry or moist skin, rashes, ulcers, urticaria changes in color and shape of the fingernails. Musculo - skeletal system: bony deformities, joint pain and /or swelling, limping, loss of function of limbs or joints, leg swelling.

22. 7. Review of System… N ervous system: S eizures, weakness, P aralysis, numbness or loss of sensation, T ingling sensation, T remor P oor memory, headache, disturbance of speech, Fecal and/or urinary incontinence. Delusion, hallucination etc

23. SAMPLE HISTORY OF ASTHMA I\D : This is _________ a 6 years old boy from Dessie town (asthma more common in urban town) currently attending lower KG at school . C/C : cough and wheeze of 2 days duration HPI : He was relatively healthy 2 days back at which time he started to experience an intermittent dry cough which worsens at night time and sometimes early in the morning but it is not associated with feeding (r/o: Gastro esophageal reflux). His mother also noticed a noisy breathing like a wheeze which is not associated with runny nose, sneezing and nasal stiffness (r/o: common cold). She denies that he has any prior wheezing episodes. Associated with this, he also has history of difficulty of breathing and difficulty of keeping up with his friends at school during different physical activities and playing. For these reasons, he discontinued to attend school for 2 days. Yesterday, his symptoms worsened during day time while playing and jumping around the house with his brother and had a difficulty of catching his breath and continuous cough. Then his mother rushed him to this hospital emergency department and he was given a drug which is inhaled through his mouth. After few minutes he became well. He has a past history of food allergy for peanut butter and a skin allergy. He is fully vaccinated. (RF for pneumonia, some etiology of acute bronchiolitis

24. He was first exclusively breastfed for 6 months and had been breastfeeding for 2 years. (RF for acute bronchiolitis ). He lives in a total family size of 5. He has one big brother aged 8 years, one younger sister aged 3 years, and his both parents. All of them are healthy. They live in a house with 3 rooms, 2 of them have a single window in each while the other has 2 Windows and 2 doors which is separated from the kitchen and toilet . They have no any animal in the house. (RF for acute bronchiolitis, pneumonia). He started to sit unsupported at age of 8 months and walk steadily unsupported at age of 1 and half years. At age of 4, he started to run up and downstairs, to dress and undress himself without help and to speak fully understandable sentences. (If failure to thrive- CF, immunodeficiency). He was born by spontaneous vaginal delivery as his other siblings at gestational age of 39 weeks with a birth weight of 2.5 kg with no neonatal and maternal complications. (Congenital abnormalities or bronchopulmonary dysplasia ) Otherwise, He has no history of previous asthma diagnosis and treatment He has no history of second-hand tobacco and other smoke exposure. (Bronchiolitis, asthma) He has no history of clear nasal discharge, sneezing (Bronchiolitis, transient asthma, pneumonia) He has no history of fever. (Bronchiolitis, pneumonia) He has no history of choking (Foreign body aspiration)

25. He has no history of difficulty of swallowing and any neurogenic disease. (Swallowing disorders ) He has no history of recurrent upper respiratory tract infection and poor weight gain. (Cystic fibrosis, immunodeficiency, ciliary kinetic disorders ) He has no history of food regurgitation or vomiting (Gastroesophageal reflux) He has no history of difficulty of making a sound and throat thightness . (Vocal cod dysfunction) He has no history of prior surgery like lung transplantation. (Bronchiolitis obliterans) He has no personal and family history of cardiac disease (r/o congenital heart disease), asthma, cystic fibrosis, immunodeficiency, TB, renal disease and RVI.

26. Reference Bates’ Guide to Physical Examination and History Taking, 10 th edition. Physical Diagnosis for Health Science Students ,University of Gondar.

27. Thank You