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HISTORY TAKING & GENERAL EXAMINATIONBy Dr. Zahoor

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History TakingImportant Points

Look confident

Welcome the patient saying Asalam O Alaikum

Shake hand with patient

Introduce yourself – I am so and so medical student

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Important Points

Explain that you wish to ask some questions to find out what happened

Make sure patient is comfortable and curtains are in place

Confirm patient’s name, age, occupation

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Importance of History

Ask principal symptoms and allow the patient to describe

Inquiry about the sequence of symptoms and events

Don’t ask leading questions in the beginning

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Usual Sequence of History

Chief complaint with duration History or present illness Past history e.g. past illness,

admission, surgery Drug history including allergies Family history Personal and social history –

smoker/not, travel, animal contact

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History of Present Illness

With all symptoms obtain details like - Duration - One set – acute or gradual - Constant or periodic - Frequency - Precipitating or relieving factors - Associated symptoms

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Example

Chest pain – 2 monthsAsk Site of pain

Character – feeling pressure, dull, stabbing, shooting

Radiation

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Example (cont)

Severity – interfere with work or sleep

H/O this pain before

Pain associated with nausea, sweating e.g. angina

Note – When patient is unable to give history, then get necessary information from friends, relative

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Usual Sequence of Events in Patient Care

History Examination – General Examination – Systemic

Examination Problem list Differential diagnosis and most likely

diagnosis Investigations Diagnosis confirmed Treatment

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General Examination

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General Examination

General Examination includes - General appearance - Alertness, mood, general

behavior - Hands and nails - Radial pulse and blood pressure - Lymph node – axillary, cervical - Face, eyes, tongue - Peripheral oedema

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General Examination

General appearance

Does the patient look ill ? Alert, confused, drowsy Co-operative, happy, sad Obese, muscular, wasted In pain or distressed

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General Examination

Hands and nails

Hands Unduly cold, warm, cold and sweaty (anxiety,

sympathetic over activity) Peripheral cyanosis Nicotine staining Raynaud’s Palms – palmer Erythema may be normal, also occurs with chronic liver

disease, pregnancy Dupuytren’s contracture – thickened palmer skin to

the flexor tendons of fingers (fourth finger)

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General Examination

NailsClubbing The tissue at the base of nail are thickened The angle between the base of nail and adjacent

skin of finger is lost Nails become convex both transversely and

longitudinally

Causes - heart – infective endocarditis - lung – carcinoma bronchus, Bronchiectasis, fibrosing alveolitis - liver cirrhosis - Crohn’s disease

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General Examination

Nails (Cont)

Koilonychia – Concave nail (iron deficiency anemia)

Leukonychia – white nails (cirrhosis liver) Splinter hemorrhages - Infective endocarditis Pitting – psoriasis Onycholysis – separation of nail from nail

bed Psoriasis, Throtoxicosis

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Finger clubbing

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Koilonychia – spoon shaped nail from iron deficiency

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Leuconychia

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Splinter Hemorrhage in fingernails in bacterial

endocarditis

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Pitting of nails in Psoriasis

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Dupuytren’s contracture- association Diabtes

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General Examination

Face, eyes, tongue Mouth – look at the tongue moist or dry - Cyanosed (central) Central cyanosis – blue tongue Cause: - Congenital heart disease e.g. fallot’s

tetralogy - Lung disease e.g. obstructive airway disease Peripheral cyanosis – blue fingers denotes inadequate peripheral circulation, tongue will be pink

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General Examination

Face, eyes, tongue (cont)

Mouth Look at the teeth – dental hygiene,

caries Look at the gums – bleeding, swollen Smell patient’s breath - Ketosis – diabetes (sweet smelling

breath) - Foetor – hepatic failure (musty

smell) - Alcohol

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General Examination

Face, eyes, tongue (cont)

Eyes Look at the sclera – for jaundice (yellow

sclera) Look at lower lid conjunctiva – anemia (pale,

mucous membrane of conjunctiva) Eye lid – yellow deposit (Xanthelasma) Puffy eyelid e.g. general oedema (Nephrotic

syndrome) , thyroid eye disease (myxoedema)

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General Examination

Eyes (cont)

Red eye – Iritis, conjunctivitis, episcleritis White line around cornea, Arcus senilis –

suggest hyperlipidaemia in younger patient, but has little significance in elderly

White band keratopathy – hypercalcaemia - Sarcoid - Parathyroid – hyperplasia - Lung oat – cell tumor - Vitamin D excess intake

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Central Cyanosis of tongue

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Peripheral Cyanosis

hand and feet

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Jaundice

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Puffy eyes

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Xanthelasmata

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Arcus senilis

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Kayser Fleischer rings(Copper deposition in Wilson’s

disease)

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Myopathic face

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Severe pitting edema of the legs

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Erythema nodosum (Sarcoidosis, Inflammatory Bowel

Disease)

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Pyoderma gangrenosum(Inflammatory Bowel Disease

– Crohn’s and Ulcerative Colitis)

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Please remember to cover the patient and THANK him/ her at the end of examination.

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Thank you