history taking and physical examination.pptx

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1. Introduction to History Taking and Physical Examination Dr. Samuel Shimelis (MD) 3/10/2024 DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

2. Outline Introduction History taking Physical examination Techniques of skilled Interviewing DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

3. Objectives To explain components of comprehensive History taking To discuses Physical examination components To list Techniques of skilled Interviewing DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

4. Introduction In care of the suffering one needs to have technical skill and human understanding in addition to scientific knowledge Skilled interview is mandatory to illicit important information relevant to current illness Physical examination without proper history is like looking for an object in darkness DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

5. cont... laboratory should not dictate over meticulous clinical evaluation careful communication, observation and study of the patient can not be replaced by investigations DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

6. The Comprehensive health history Date and Time of History Identifying Data Age, gender, marital status, education, occupation , religion, residence area, date of admition , and bed number T he source of history R eferral Mode of arrival Reliability: should be documented if relevent . e.g. “ the patient is vague when describing symptoms and unable to specify details” DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

7. cont... Chief complaint (s) Should be documented in patient’s word It could be one or more It Has to be time bounded DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

8. cont... History of present Illness Elaboration of HPI should be chronological , complete and clear The principal symptoms should be well characterized with descriptions of location, quality, quantity of severity, timing( onset, duration and frequency ), aggravating and relieved factors , associated symptoms It is also important to include “ pertinent positives and pertinent negatives and Risk factors Use open ended question DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

9. cont... medication, smoking, alcohol drinking habit, allergy should be assessed Past History: childhood illness: MMR, whooping cough medical, surgical, gyn / obs , and psychiatry Family History: mother, father, sibling, grandparents, children, grandchildren family hx chronic illness age, health, if death ( date, cause, age at time of death) DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

10. cont... Personal and Social History It includes the patient’s personality and interests, sources of support, coping style, strengths and fears It should include the childhood time, education, occupation, life style habits, home situation and diet Social interaction history Baseline level of function in elderly individuals DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

11. cont... Review of Systems Start with fairly general question then shift to specific question about systems that may be of concern e.g. how are our ears and hearing?.. any trouble with your heart... how about your breath and lung.... It may uncover problems that the patients has overlooked, particularly in areas unrelated to the present illness. Significant health events ( major illness or parent’s death) need evaluation and should be included in HPI DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

12. cont... Systemic Review C omponents HEENT : Head: headache, injury, dizziness, lightheadedness Eye: visions status, glasses or contact lenses, pain, redness, excessive tearing, blurring of vision Ears: hearing status, tinnitus, vertigo, ear aches , discharge Nose and Sinuses: discharge, itching nose bleeding , sinus trouble Throat ( or Mouth and pharynx): toothache , bleeding gums, dentures DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

13. cont... LGS : lumps , pain, or discomfort, nipple discharge RS: cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy CVS : chest pain, hx of HTN , rheumatic fever, palpitation, dyspnea, orthopnea, PND, edema GIS: d/t swallowing, heartburn, appetite, nausea , vomiting , change in bowel movement, rectal bleeding, constipation, diarrhea, abdominal pain, belching , distention , jaundice DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

14. cont... GUS: urinary frequency, polyuria, dysuria, hematuria, flank pain, lower abdominal pain, ulcer, discharge, swelling, hesitancy, dribbling, testicular pain, mass, menstrual hx MSS: muscle or joint pains, stiffness , backache, d/t moving the limb INT: rashes, lumps, sores, itching , dryness, color change, changes in hair or nails CNS: seizures, weakness, paralysis, numbness, loss of consciousness, tingling or “pins and needles, tremors DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

15. Cont … Example of patient’s History ID : This is Mrs Xx a 35 years old orthodox Christian farmer from keyet admitted on yekatit 27/2016 E.C in IMD on bed no 4 Source of referal : self referal Mode of arrival: on foot C/C : Abdominal pain HPI: This is a 35 years old female patient present with crampy periumblical abdominal pain associated with this she has also mucus and blood mixed watery stool 6-8 times/day for the past 2 days, tensimus , high grade intermittent fever, abdominal bloating and decreased appetite. She has taken unspecified PO medication for abdominal pain but has no improvement DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

16. Cont … Otherwise: She has no hx nausea or vomiting, has no hx of passing faeces or flatus, has no dysuria, urgency or frequency, she has no previous abdominal surgery, has no hx of smoking and alcohol consumption How do you see the given history???? DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

17. Cont … E.g. ID: This is Mrs. Xx a 35 years old female orthodox Christian farmer who has no formal education from keyet admitted on yekatit 27/2016 E.C at 1 NLT in IMD on bed no 4 Source of History : herself Source of referral: self referral Mode of arrival: on foot Reliability: seems reliable C/C : Abdominal pain of 3 days duration HPI: This is a 35 years old female patient present with gradual onset moderate crampy periumblical abdominal pain of 3 days duration with no radiation and aggravating and reliving factor. associated with this she has also mucus and blood mixed watery stool of 6-8 times/day for the past 2 days, tensimus , high grade intermittent fever, abdominal bloating and decreased appetite. She has taken unspecified PO medication for abdominal pain but has no improvement. She usually use spring water for drinking and cooking, she also lives in a family of 6 members and there is similar cases in her village DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

18. Cont … Otherwise: she has no hx nausea or vomiting, has no hx of passing faeces or flatus, has no dysuria, urgency or frequency, she has no previous abdominal surgery, has no hx of smoking and alcohol consumption Family hx : her mother and father are 59 and 67 years old and health respectively, has no family hx DM/HTN or renal disease DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

19. Physical Examination Approach General Appearance: Acute, chronic, acute on chronic Grooming, personal hygein, way of talking, walking, facial expressions, weight, posture, gait affect, Vital signs: PR, RR, T, BP, PSO2, weight and height DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

20. Cont … DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

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23. cont... HEENT: Head: hair , scalp, skull, face Eye : conjunctiva, sclera, the eyelids, opthamoloscope examination Ear: pinna, tragus, mastoid, otoscope examination, weiber’s and rinnes test Nose and throat: nostrils, nasal septum, nasal bone, sinus palpation, lips, tongue, gum, teeth , palates tonsils and pharynx DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

24. cont... LGS: lymph node palpation, thyroid, breast, tastes RS: Inspection: cyanosis, breathing, intercostal , subcostal suprasteranal retraction, chest symmetrical, scan, shape of the chest, Palpation: tenderness, TF, chest expansion, Purcussion: dullness, diaphram excursion Ausculation: breathing sound, added sound DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

25. cont... CVS: Venous: raised JVP, distended neck vein Artery: PR, R-R or R- femoral delay Precordial examination: Inspection: active or quite precordial, AP, PMI Palpation: valvular areas, heave, thrills Auscultation: s1 and s2 sound, murmur, s3 or s4 sound DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

26. cont... Abdomen: Inspection: the shape of the abdomen, movement respective of breathing, any scar, shape of umbilicus, distended vein, visible pulse of peristalsis, hernia sites Palpation: S uperficial : tenderness or mass D eep : tenderness, mass, organomegaly DRE Percussion : tympani or dullness, TVLS, sign of fluid collection Auscultation: bowel sound, bruits, venous ham DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

27. cont... GUS: Inspection: swelling , ulcer, fissure, discharge Palpation: CVAT , mass , PV examination PVR examination MSS: Look: swelling, deformity, scar, fracture, angulation, bleeding, Feel: hotness, tenderness, crepitation, mass Move: range of motion Measure: the length, discrepancy of the limbs DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

28. cont... INT: lesions, lumps, discharge, capillar y refill NS: Mental status: COTPP CN GCS Motor: tone, power Reflex Sensory: touch, pain, pressure, proprioceptive Coordination Meningeal sign DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

29. Cont … E.g. for reporting physical examination result T his is a 35 years old female patient who present with moderate crampy periumblical abdominal pain with blood and mucus mixed watery diarrhoea of 03 days duration and high grade intermittent fever of same duration; O n physical examination GA: she is acutely sick looking V/S: PR: 102bpm , T: 38.7 c , BP: 80/60mmHg ,RR: 28bpm , Pso2: 94 % with ATA , HEENT: she has pale conjunctiva , Non icteric sclera, dry buccal mucosa, no sunckening of eye ball, Abdomen: flat abdomen, direct tenderness on the umbilical area, no organomegaly , no sign of fluid collection, GUS: no CVAT, INT: capillary refill is <3 second, hot extremity, no palmar pallor , CNS: she is COTPP, GCS is 15/15 Assessment : ?sepsis of GI focus + mild dehydration 2ry to GI loss DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

30. After History and physical examination completed Investigations Laboratory: CBC, stool, urinalysis, OFT( RFT, LFT, TFT), H-pylori, RF, uric acid, widal , weil feilx , BF, RBS… Imaging: U/S, CXR,CT,MRI, upper GI endoscopy, Pathology: FNAC, excisional biopsy, peripheral morphology, bone marrow aspiration, bone marrow biopsy Management: outpatient vs inpatient DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

31. Techniques of skilled Interviewing Active listening Adaptive questioning Non verbal communication Facilitation Echoing Empathic responses Validation Reassurance Summarization Highlighting transitions DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

32. References Bate’s guide to physical examination and history taking DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE

33. Thank you DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE