History and examination

• المقرر الدراسي: 441 MED

History and examination
 
The main purpose of the medical interview is to obtain information about the patient’s illness in order to reach a diagnosis. Diagnosis means identifying and characterizing the disease that the patient has. It is a mental exercise that depends on three basic components.
1.     History of illness
2.     Physical examination
3.     Diagnostic procedures (Laboratory of radiological, etc.)
Patient history is the most important component as 80% of diagnosis can be made from history alone. Physical examination increases the diagnostic yield by 10% and laboratory investigations by another 10%. Therefore taking a good medical history is essential in providing good patient care.
Clinical manifestation of disease are classified as:
1.     Symptoms:Abnormal sensations/changes that the patient feel or observe  (e.g. pain, weakness, shortness of breath).
2.     Sings:Abnormal findings detected by physician on examination (e.g. high temperature, enlarged liver, heart murmur).

HISTORY TAKING:
The objective of taking a medical history is to obtain information about patient illness to make a diagnosis, assess the severity of illness and evaluate its effects on patient’s bodily functions and life. It also serves to establish a relationship between the physician and the patient. The medical history consists of eight components:
1.     Personal data.
2.     Chief complaint (presenting illness)
3.     History of presenting illness
4.     Past history (medical and surgical)
5.     Family history
6.     Social history
7.     Drugs and allergies
8.     Review of systems
 
GENERAL GUDELINES:

Obtaining a good history and physical examination depends largely on patient’s cooperation and confidence in his physician. Students should learn ways to facilitate communication with patients and increase their cooperation during history taking and physical examination. The following are helpful guidelines:
1.     At the beginning, greet the patient and introduce yourself to him: call the patient by his/her first name (if young, use brother/sister: if old, use uncle/aunt). Ask the patient “how is he feeling now?”
2.     Put the patient at ease, make sure that he is comfortable, e.g. in posture, light and
Temperature. Draw the curtains around him to ensure privacy. For females, a female attendant or nurse has to be present.
3.     Show the patient that you are interested in him: by paying attention to his words,
Making sure he is comfortable, answering his needs (e.g. blanket, glass of water , bathroom, etc.). Your posture, words and facial expression should show continuous
Attention to the patient.
4.     Facilitate communication to promote free flow of information. This id done by
Asking general open-ended questions. Encourage the patient to speak freely about
His problem. Show interest in his statements by nodding your head, saying ÿes”, ähah”, änd then repeating the last phrase of his account.
5.     Avoid actions or words that reduce communication, e.g. using technical terms
(patients did not study pathology) or interrupting patient’s speech. Avoid actions that suggest to the patient that you are not interested in him, e.g. taking to another person while the patient talks, reading the hospital chart or book or not actively listening to him.
TECHNIQUE OF HISTORY TAKING
For proper history taking, you are advised to use a systematic approach covering the major components of the medical history mentioned above. I advise you to use the following method:
Step 1: Introduction

• Greet the patient (as above)
• Introduce yourself “I am (mention your name), I am part of the medical team responsible for your care, and I wish to speak to you about your illness”.
• Make sure he is comfortable … (as above), put him at ease.
• Ask “how are you feeling now?” “where are from, uncle?”
• To improve communication, you may chat with him about the weather, his city or
Region, etc.


Step 2: Personal data
Get the patient’s name (preferably from records), age, sex, nationality, and area of
Residence, occupation.

Step 3: Chief complaint (presenting illness)

• Ask the patient about the symptom, complaint or problem that brought him to the
Hospital, e.g. “What was the problem that brought you to the hospital? “When did
It starts?” “Were you well before that?” “What was the first thing that you felt?”
Here, encourages the patient to speak freely, and give a full account of his problem.
Do not interrupt except by nodding your head or saying “Yes “, “ah “. “What else “? When the patient finishes his initial description, ask him “are there any other problems “. Repeat until the patient has nothing to add. Avoid suggestions and do not ask leading questions, e.g. “Do you have loin pain?”.
Your objective here is to identify the main symptom or symptoms that the patient has and their duration. This is the chief complaint(s).

Step 4: History of present illness (HPI)
Here, your objective is to analyze or dissect the main symptom(s) in details, and in
A chronological order. Symptoms (e.g. pain) are usually characterized by the Following features:
1.     Body site (exact are a of body affected)
2.     Duration – since the beginning of the symptom
3.     Radiation – to other areas of the body
4.     Character – describe the symptom (what is it like) and clarify what the patient means by symptom.
5.     Onset – did it start gradually or suddenly
6.     Severity – mid, moderate, sever
o    Does it interfere with daily activity or sleep?
o    Frequency of the symptom (if intermittent)
o    Size (swelling), volume (fluid, sputum, etc.)
7.     Aggravating factors – factors that make it worse.
o    Precipitating factors – factors that lead to it.
o    Reliving factors – factors that make it better.
8.     Course of the symptom since the beginning: did it improve or get worse? If Multiple attacks, frequency and duration of attacks
9.     Associated symptoms: these include:
o    Positive symptoms within the same system or other systems.
o    Negative symptoms of the same system (state that they are absent)
o    General symptoms of disease (fatigue, weight loss, anorexia, fever) whether present or absent.
Step 5: Past History

• Ask about any significant medical problems in the past – since childhood. Hospital 
Admissions, trauma, fractures, surgical operations, blood transfusions. Mention diseases/ surgeries and the dates (year).
• N.B.: Remember that past medical history includes illnesses that happened in the past and are cured. Chronic diseases that started in the past and are still present (like diabetes mellitus, hypertension, rheumatoid arthritis) are not past medical problems, they are current problems and should be included in history of present illness.

 
Step 6: Family History
 
Ask about:

• Family members and their state of health (parents, brothers and sisters, wife and  Children)
• Illnesses and deaths in the family
• 
Any similar illness family members

Step 7: Social History
Ask about:

• Nature of occupation – recent and old
• Home surroundings
• Any problems with work or family members or financial problems
• Habits: Drinking/smoking
• History of travel


Step 8: Drugs and Allergies

• Is the patient using any drugs? Mention names, dosages.
• Is the allergic to any drugs or substances?

Step 9: Review of system
General :   Anorexia, weight loss, fatigue, fever, sleep disturbance
  
CVS  :   Chest pain, dyspnea, cough, hemoptysis, palpitations, syncope,
        Ankle swelling, leg pains.
  Respiratory :   Chest pain, dyspnea, cough, sputum, hemoptysis, wheezing.
G.I.T.  :   Nausea, vomiting, dysphagia, heartburn, abdominal pain,   
      Distension, dyspepsia, diarrhea, constipation, jaundice.
Urinary : History of loin pain, dysuria, hematuria, frequency, polyuria,
       Hesitancy, difficulty in micturition, urethral discharge 
Locomotor :   Joint pain, swelling, muscle pain, weakness, backpain, bone pain.
C.N.S. :   Headache, dizziness, loss of consciousness, seizures, visual or
Auditory symptoms. Weakness and numbness in any part of the   Body.
Skin  :   Skin lesion, itching
Blood  :   History of blood loss, bleeding tendency