Lec-1. History taking clinical exam(0).pptx

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1. HISTORY TAKING

2. Learning objectives Introduction and describing aim & objectives Chief complaints History of present illness Past medical history Drug history Family history Social history Systemic enquiry

3. INTRODUCTION & IMPORTANCE  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 Obtaining an accurate history is the critical first step in determining the Etiology of a patient’s illness A large percentage of time (70%) you will actually be able make a diagnosis based on the history alone

4. HOW TO TAKE A HISTORY The basis of a true history is good communication between doctor and patient. It takes practice, patience, understanding and concentration. Always listen to the patient they might be telling you the diagnosis Be conversational rather than interrogative in tone.

5. INTRODUCTION I ntroduce yourself Give your name and your job I dentity Pay full attention and confirm you’re speaking to the correct patient (name and date of birth) P ermission Confirm the reason for seeing the patient (“I’m going to ask you some questions about your cough, is that OK?”) Create patient appropriately in a friendly relaxed way Confidentiality and respect patient privacy

6. PATIENT PROFILE Date and Time Name Age Sex Religion Marital status Occupation Address

7. CHIEF/PRESENTING COMPLAINTS Ask the patient to describe their problem using open questions (e.g. “What’s brought you into hospital today?”) The presenting complaint should be expressed in the patient’s own words (e.g. “I have a tightness in my chest.”), usually a single symptom, occasionally more than one complaints e.g.: fever, headache, pain etc.  If there is more than one complaint, it should be written according to chronological order ( Fever-2 weeks, productive cough- 1 week) etc Do not interrupt the patient’s first few sentences if possible

8. HISTORY OF PRESENTING COMPLAINT Ask the patient further questions about the presenting complaint A useful mnemonic for pain is “SOCRATES“ S ite O nset C haracter R adiation A lleviating factors T iming E xacerbating factors S everity

9. PAST MEDICAL HISTORY Ask the patient about all previous medical problems. Ask about these important conditions specifically MIJTHREADS M yocardial infarction J aundice T uberculosis H ypertension R heumatic fever E pilepsy A sthma D iabetes S troke C ancer (and treatment if so)

10. PAST SURGICAL HISTORY Time/place/ and what type of operation Note any blood transfusion and blood grouping

11. DRUG HISTORY All medications  that they take for each medication ask them to specify: Dose, frequency, route and ( i.e whether they regularly take these medication).   If they take medication weekly ask what day of the week they take it. If they take a medication with a variable dosing (e.g. Warfarin)  ask what their current dosing regimen is Allergies Does the patient have any allergies? If allergic to medications, clarify the type of medication and the exact reaction to that medication.

12. FAMILY HISTORY Any familial disease/running in families e.g. breast cancer, IHD, DM,HTN schizophrenia, Developmental delay, asthma etc. Ask the patient about any family diseases relevant to the presenting complaints (e.g. if the patient has presented with chest pain, ask about family history of heart attacks). Enquire about the patient’s parents and sibling and, if they were deceased below 65, the cause of death

13. SOCIOECONOMIC HISTORY Alcohol intake amount, duration and type Tobacco use  amount, duration and type Employment history Particularly relevant with exposure to certain pathogens e.g. asbestos, where you need to ask whether they have  ever  been exposed to any dusts Home situation Travel history

14. SYSTEM REVIEW

15. SYSTEM REVIEW

16. SUMMARY Provide a short summary of the history including: Name and age of the patient, presenting complaint, relevant medical history Give a differential diagnosis Explain a brief investigation and management plan

17. PHYSICAL EXAMINATION INSPECTION PALPATION PERCUSSION AUSCULTATION OLFACTION Light Deep Direct Indirect Fist Direct Indirect