History Taking And Examination

prepared by:
Dr. Emad Naif Ali
M.B.ch.B
Contents
• 1- history taking.
• 2- physical(general examination).
Easy Way To Take The History
• Greeting the patient.
• Start by Saying Hello and introduce your self (shake hand, say
Hajia chawani).
• Take permission.
• Respect privacy & comfort.
• Sit on chair (not bed).
• Explain for the patient about the interview.
How to ask questions
• Start with open ended questions (tell me about your illness)
then ask directive open ended questions to clarify issues (e.g.
can you remember when your complaint first started?).
• You may need to use list (MCQ) questions.
• Use close ended questions (yes/no) only if you can not get
information by other ways.
• Avoid jargon or unnecessarily emotive words (e.g. this is
normal).
• Clarify what the patient exactly means by the answer esp. for
symptoms like dizziness, numbness, blurred vision.
Content of history taking
• Identifying data( patient's demography).
• Chief complaint & duration.
• History of the Present Illness.
• Review of systems (ROS).
• Past Medical History (PMHx).
• Past Surgical History (PSHx).
• Drug history & allergy to drugs.
• Family history.
• Socioeconomic history.
• Menstrual history.
• Vaccination and blood transfusion.
• Travel history.
Patient's demography
• 1. Name: mention the triple name. Name makes
communication easier, get confidence of patient.
• 2. Age: If they don’t know, associate the age with the major
events in their life e.g. their marriages or those of their
siblings…etc.
• Pediatrics: < 18 y. (13 y. in Iraq)
• Young adults: 18 to 40 or 45 years
• Middle age: from 40 or 45 to 64 years.
• Elderly: ≥65 y.
• 3. Sex: Sex is the biological difference. Gender is the
psychological & socio-cultural difference between males &
females.
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• 4-Address: certain areas are endemic with some diseases.
• 5-Occupation: Ask about the exact nature of patient work e.g.
heavy work, standing for hours during work…etc.
• 6-Religion
• 7-Marital Status.
• 8-Date of Admission.
• 9-Date of examination.
• 10-source of history: may be sometimes you receive a patient
that he/she mentally un sable or not fully consciousness, that
time you maybe take the history from the relatives( father,
mother, brother, sister or friend).
Chief complaint and duration
• It is the problem made the patient seek medical help
• Use patient’s own words
• Not > 3 complaints (with duration of each)
• They should be short
• Don't use medical term.
History of the present illness
• Is the analysis of the chief complaint in details with using this
questions:
• 1. Timing:
• Onset: sudden or gradual, spontaneous or after a specific
event
• Frequency: continuous or intermittent (at which time)
• Duration of attacks & intervals

• 2. Site: ask the patient to point, determine the exact site

(anterior, posterior…etc).
• 3. Radiation: extension of symptom while the initial symptom
persist & should be of the same character.
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• 4. Quality:
• Burning.
• Aching: dull continuous pain e.g. in chronic arthritis
• Colicky: intermittent gripping pain
• Crushing or choking: e.g. myocardial infarction
• Stabbing: e.g. in ruptured tendon
• Throbbing: e.g. in abscess
• Tearing: e.g. in aortic dissection
• 5. Quantity (severity): mild, moderate or severe. Indicators are:
• Interference with sleep or activity
• Need for admission
• Need for continuous treatment
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• 6.Progression: worse, improving, static (?
• make the curve of progression)
• 7. Relieving & Aggravating Factors.
• 8. Associated symptoms
• 9. Other symptoms of affected system
• 10. Hospital Course :
• - Investigations .
• - Medications & Interventions .
• - Improving OR Not .
Review of the other systems
• 1-General: WET2 BeDS
• Weight changes: from measurements, others people, loosening
of shoe, ring, watch or belt.
• Energy: tiredness, fatigue, lassitude, malaise
• Temperature:
• Fever (continuous, intermittent), chills, rigor
• Cold or hot intolerance
• Sweating: night sweats
• Excessive Thirst
• Behavioral (mood) changes
• Dermatology: itching, rashes, photosensitivity, subcutaneous
bleeding, bruises, hair loss
• Sleep changes
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• 2. Cardiorespiratory: BC4DEF2 S2
• Palpitation (beating)
• Chest pain: exertional, rest,
• Cough (dry, productive, blood)
• Cyanosis
• Claudication (pain in legs on walking)
• Dyspnea: exertional, paroxysmal nocturnal dyspnea, orthopnea
(dyspnea on lying down), NYHA (New York Heart Association) class
• Ankle edema
• Fainting attacks: dizziness, syncope
• Inhalation of foreign body
• Sounds: wheezes, stridor, hoarseness of voice
• Sore throat
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• 3. GIT:
• Appetite & nutrition
• Mouth: Taste changes, oral ulcers, dental problems
• Water brash: sudden salivary hyper secretion
• Heartburn: sub- or retrosternal burning sensation
• Regurgitation
• Dysphagia
• Nausea / vomiting / Hematemesis
• Abdominal pain
• Abdominal distension
• Stool (BCD): bleeding, constipation, diarrhea
• Jaundice
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• 4. GUT:
• Urine: amount, color (blood), odor, air, foamy urine
(proteinuria)
• Renal: colic, pain
• Symptoms of urination: dysuria, frequency, nocturia, polyuria,
strangury (painful & fruitless desire to urinate)
• Symptoms of bladder outlet obstruction: Hesitancy, Urgency,
caliber, Straining, Interrupted stream, Incontinence,
Retention, Dribbling
• Genital: Impotence, Menstruation, Dyspareunia, Discharge,
Genital ulcers, Contraception
• Breast & secondary sexual characteristics: Galactorrhoea
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• 5. CNS: from cerebral cortex to peripheral nerves
• Headache
• Syncope
• Memory and concentration changes
• Speech defect
• Blurred vision, diplopia,
• Hallucinations (visual, auditory), abnormal taste or odors
• Hearing problems (deafness, tinnitus)
• Abnormal movements (fits, tremor)
• Weakness
• Vertigo, incoordination.
• Parasthesia, neuropathic pain
• Sphincter disturbances
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• 6. Musculoskeletal System: PLWGS2
• Pain: Painful joints, myalgia, painful bone, neck pain
• Limitation of movement: difficulty in dressing or walking
• Weakness
• Gait: limping, falls
• Swelling (calf, joints)
• Stiffness
Past medical history(P.M.Hx)
1- For each condition, determine:
• When diagnosed?
• How diagnosed?
• How treated?
• Whether controlled or not?
2. Ask about:
• Similar conditions
• Endemic diseases: tuberculosis,
• Chronic disease: HT, DM, cancer, renal disease
• Admissions to hospitals.
• Any blood transfusions (& any HSR to blood)
• Hx of radiotherapy, psychotherapy, physiotherapy
Past surgical history(P.S.Hx)

• 1.Previous operations or trauma

• 2.Any postoperative complications
• 3.Problems with anesthesia
• 4. Blood transfusion
Drug history and allergy to
drug
• 1.Drugs taken by patient: name, dose, duration of use,
compliance, response, side effects, monitoring
• 2.Hypersensitivity: name of drug, form of HSR
Family history
• Number & age of family members.
• Age & health of spouse. Previous marriages.
• Hx of similar condition
• Hx of endemic disease
• Chronic disease: HT, DM, cancer, renal disease
• Hx of hereditary disease: consanguinity is important in
autosomal recessive dis & affected females are important in X-
linked diseases.
• Sudden premature death in 1st degree relatives at young age
• Genital infections in spouse
• Problems with anesthesia in 1st degree relatives
Socioeconomic History
• Social status: good, moderate, poor
• Personal habits:
• Smoking: Calculate pack years= no. of packs × years of
smoking.
• No. of packs= No. of cigarettes / 20
• Alcohol: Type , Quantity, CAGE Questionnaire for alcohol
dependence
• Hobbies: exposure to birds.
• Housing: no. of rooms, owned or rented, how the patient live
at home, any person to take care of him, water source, any
animal at home
Menstrual history

• Menarche
• Menopause
• Duration of cycles & menstruation
• Interval duration
• Amount: number of pads changed
• Associated symptoms: like pain.
Blood transfusion and
vaccination history
• Ask about the blood transfusion and if there is any problem
related to the transfusion process.
• Ask about vaccination.
Travel history
• Ask the patient if they were travelling to an area.
Example for how to present
your history
• Mr., Mrs. or Miss (name) is a (age) - years old (sex) who is (job)
from (address) & is a known case of (major dis.: HT, DM, CAD,
etc.) presented on (date) chiefly complaining of (CC) for
(duration). The condition started (HPI). On further systemic
inquiry (ROS). His PMHx is significant for (positive diseases) &
there is no history (important negatives). His surgical history
(PSHx). He is taking (D. Hx), & there is (family history). The
patient is of (social state & history).
Examples of Symptom Analysis
(Chest Pain, angina)
• Timing: sudden, intermittent for 5 minutes.
• Site: central (retrosternal)
• Radiation: to left shoulder
• Quality: crushing
• Quantity: moderate
• Progression: static
• Relieving factors: rest and sublingual tablets
• Aggravating factors: exertion
• Associated Symptoms: shortness of breath
• Other symptoms of affected system: no cough or palpitation.
Examples of Symptom Analysis
(Dyspnea)
• Timing: gradual, continuous.
• Site: -----
• Radiation: -----
• Quality: ------
• Quantity: mild
• Progression: worsening
• Relieving factors: rest
• Aggravating factors: exertion, lying flat
• Associated Symptoms: chest pain
• Other symptoms of affected system: no cough or palpitation.
Question for discharges in HPI
• Timing:
• Color: whether blood stained
• Consistency: loose, hard
• Amount (vol.)
• Associated symptoms
• Odor
Question for Mass Swelling
• Site
• size
• consistency
• Changing in size
• Discharge form mass
• Change in Skin over it
• Any other mass in other areas
• Associated symptom
Examination
• General examination
• Physical examination is the process by which
the physician investigates the body of a patient
for signs of disease.
• It generally follows the taking of the medical
history. Together with the medical history, the
physical examination aids in determining the
correct diagnosis and devising the treatment
plan .This data then becomes part of the medical
record.
General examination
• Important Points
• 1) Come to the right side of the patient.
• 2) Greet the patient and introduce yourself.
• 3) Take consent from the patient.
• 4) Properly expose the patient.
• 5) After examination is done, cover the patient and say thanks.
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• Physical examination includes:
• 1-General observation of the patient,
• 2-JACCOL for Jaundice , Anemia , Cyanosis ,
Clubbing of nails , Oedema of ankles and Lymph
nodes .
• 3-Inspection of face and body for evidence of
systemic or endocrine disorders .
• 4- examination of the lower limb.
• 5-Examination of the thyroid .
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• 1- General observation( appearance) of the patient include:
• Age, sex
• Position
• Consciousness
• Looking ill or well
• Dyspnic or not
• Nutritional status
• Interventions
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• 2- Face :
• does this patient look well ? Or he has abnormal facial
expression ? examples :
• Startled expression : hyperthyroidism
• Apathy , Poverty of expression and poor eye contact :
depression
• Apathy , with pale and puffy skin : hypothyroidism
• Agitated expression : anxiety and hyperthyroidism
• Moon face: Cushing syndrome
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• Clothing :
• obtain information about patient's personality , state of mind
and social circumstances by taking notes of his clothing
• Sounds : there is either abnormality in production of sound
examples :
• Hoarseness of voice :
• infective laryngitis , hypothyroidism , heavy smoking and
neurological disease .
• Or any abnormal sounds , examples : stridor or
musical wheezing .
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• Odors :
• Stale or mousy smell : ( fetor hepaticus ) in liver failure
• Sweetness of breath ( acetone ) in diabetic ketoacidosis
• Bad odor ( halitosis ) : in gingivitis , stomatitis , atrophic rhinitis
and tumors of nasal passages .
• Mouth:
• Central cyanosis
• Tongue
• Gingiva
• Teeth and hygiene
• Any ulcers or pigmentation
• Angular stomatitis
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• Posture and gait :
• in weakness and neurological disease
• Like shuffling gait in parkinsonism and Waddling gait proximal
myopathy.
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3- Hand :
posture , shape , size , color and temperature
Hand shake : look and feel any abnormalities
Cold and sweaty hands : anxiety
Cold dry hand : Raynaud's phenomenon
Hot sweaty hand : hyperthyroidism
Large sweaty hands : acromegaly
Dry coarse skin : hypothyroidism
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• Nail :
• for the shape , color and nail bed example:
• Koilonychias ( spoon shape ) : iron deficiency anemia.
• Leukonykia ( white nail ) : hypoalbuminemia and severe
anemia.
• Splinter hemorrhage : trauma and infective endocarditis
• Palmar erythema.
• Sweating
• Dupuytren's contracture.
• Splinter Hemorrhages
• ecchymosis, spider nevi, Tremor.
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• Joint :
• for any swelling , pain ,hotness and limitation of movement as
in rheumatoid arthritis .

• Muscle :
• wasting of thenar muscle as in rheumatoid arthritis ,
debilitating diseases, carpal tunnel syndrome.
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4- Leg Examination (compare both sides):
• Skin color
• Hair distribution
• Deformity
• Scars, ulcers, any lesion
• Visible veins
• Temperature
• Edema
• Tenderness
• Pulse
• Nail clubbing, between toes, peripheral cyanosis
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5- Thyroid gland :
examination for goiter ( enlarged thyroid ):
inspection : from the front of the neck for enlargement ,
symmetry ,cyst …….. while the patient swallow sip of water .
palpation : from the back for size shape , consistency and any
nodules and also for neck lymph nodes .
percussion : for retrosternal goiter.
auscultation : for any thyroid bruit .
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JACCOL
• Jaundice: is yellowing of the skin, sclera (the white of the eyes)
and mucous membranes caused by increased levels of
bilirubin in the human body.
• Jaundice either :
• hemolytic ,
• hepatocellular or
• obstructive types .
• Jaundice usually examined in sclera , oral mucous membrane
and skin .
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• Anemia:
• pale color of skin or conjunctiva, due to decrease the level of
hemoglobin below the normal ( decrease the RBC mass ) .
• anemia either due to decrease production of RBCs or increase
destruction of RBCs ..
• Anemia examined in the conjunctiva of the lower eyelid , oral
mucosa , gum , nail bed and palmer creases .
• Pallor also may be due to vasoconstriction ( shock ) or
endocrine disease (hypopituitarism ).
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• Cyanosis:
• blue coloration of lips or extremities, due to increased level of
deoxygenated hemoglobin above 5 mg/dL .
• peripheral cyanosis : which seen in the hands and feet due to
peripheral vascular disease , peripheral vasoconstriction
( Raynaud's phenomenon)
• Central cyanosis : is seen in the lips and tongue , usually due to
arterial hypoxemia ( usually cardiac or respiratory disease) .
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• Clubbing:
• Clubbing of nails (deformity of the fingernails).
• four criteria confirm clubbing:
a- loss of the normal angle between the nail and nail bed
• b-increase nail bed fluctuation
• c- increased nail curvature in later stage
• d- increased bulk of the soft tissues over the phalanges .
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• Oedema:
• edema means swelling of tissues due to increase in interstitial
fluid . types of edema :
• generalized ( due to cardiac , renal , gut or nutritional
diseases ).
• Localized ( due to venous or lymphatic obstruction , allergy or
due to inflammation ).
• Postural edema relatively common in the lower limb of
inactive patient .
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• The cardinal sign of edema on examination is pitting of the
skin , made by applying firm pressure with fingers or thumb
for a few seconds , only lymphedema and myxedema do not
pit on pressure .
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• Lymph nodes:
• site:
• neck ( sub mental , submandibular , preauricular
supraclavicular and deep cervical glands , scalene nodes ,
posterior auricular and occipital nodes ) ,
• axilla ,
• armpits( epitrochlear ) and groins.
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• Size :
• normal glands in adult seldom more than 0.5 cm diameter .
• Consistency :
• normal glands feel soft and rubbery . Pathological glands
either firm , hard , stony ……
• Tenderness :
• usually feature of infection .
• Fixation :
• fixation of glands to deep structures or skin usually indicates
malignancy .
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• And when you finish your examination, do not forget to say
(To complete my examination I would like to examine vital
signs).