HISTORY TAKING AND PHYSICAL EXAMINATION

DR VICTORY IYANAM, MB,BCH, AFMCFM, FWACP( FAM.MED)

• OBJECTIVES:
• UNDERSTANDING SKILLS REQUIRED IN EFFECTIVE
MEDICAL PRACTICE
• DEFINITIONS
• PRINCIPLES OF EFFECTIVE HISTORY TAKING
• USE OF HISTORY TAKING TO ARRIVE @ DIAGNOSIS
• CURRENT CONCEPTS IN HISTORY TAKING &
PHYSICAL EXAMINATION
BASIC SKILLS REQUIRED IN MEDICAL PRACTICE:
-DIAGNOSTIC SKILL
-COMMUNICATION SKILL
-EDUCATIVE SKILL
-COUNSELING SKILL
-THERAPEUTIC SKILL
-MANAGEMENT SKILL
-MANUAL SKILL
• GOOD DIAGNOSIS CANT BE ACHIEVED
WITHOUT GOOD HISTORY AND EXAMINATION
• APPROPRIATE TREATMENT CANT BE
INSTITUTED WITHOUT APPROPRIATE
DIAGNOSIS
• GOOD MEDICAL PRACTICE REVOLVES
BASICALLY AROUND HISTORY AND
EXAMINATION
• DEFINITION: MEDICAL HISTORY /MEDICAL
CASE HISTORY OF A PATIENT IS INFORMATION
ON THE PATIENT’S HEALTH OBTAINED BY THE
PHYSICIAN FROM THE PATIENT OR OTHER
PERSON(S) WHO KNOW THE PATIENT (AND
CAN GIVE SUITABLE INFORMATION) THAT
ENABLE THE PHYSICIAN TO FORMULATE A
DIAGNOSIS AND PROVIDE MEDICAL CARE TO
THE PATIENT.
• MEDICAL HISTORY TAKING IS AN INTERACTION
WITH PATIENT OR CLOSE RELATIONS( OR
PERSON(S) CLOSE TO THE PATIENT) THROUGH
SYSTEMATIC COMMUNICATION TO FIND OUT
WHY THE PATIENT COME TO THE HOSPITAL
(ACTUAL REASON FOR COMING)
• IT IS A FORM OF DOCTOR-PATIENT INTERACTION
THAT LEADS TO DIAGNOSIS AND FORMULATION
OF CARE PLAN FOR THE PATIENT.
• USUALLY ABBREVIATED AS :
-HX OR hx.
NOTE: PROVICIENCY IN MEDICAL HISTORY TAKING
AND EXAMINATION IS ACQUIRED WITH
PRACTICE- THE MORE PATIENTS YOU SEE AND
CLERK, THE MORE EXPERIENCED AND
PROVICIENT YOU ARE.
• HISTORY TAKING AND EXAMINATION IS
PRACTICAL MEDICINE
• IMPORTANCE OF MEDICAL HISTORY IN CLINICAL
MEDICINE :
1) IN MOST CASES, HISTORY
CONSTITUTES/PROVIDES THE HIGHEST %TAGE OF
INFORMATION NEEDED FOR DIAGNOSIS
• HOW DO YOU ARRIVE @ DIAGNOSIS:
-HISTORY-60%
-EXAMINATION-40%
-INVESTICATION-20%
• IN SOME CASES 100% DIAGNOSIS IS MADE WITH HISTORY
-EXAMPLES-
-MALARIA IN RURAL AREAS
-PID IN YOUNG SEXUALLY ACTIVE GIRLS
-GONORRHOEA IN SEXUALLY ACTIVE MALES
-TETANUS IN LOCAL FAMER WITH TWITCHING
-RAPE IN A YOUNG GIRL WITH LATE PRESENTATION
-MIDDLE AGED WOMAN WITH SYMPTOMS OF MENOPAUSE
2) GOOD HISTORY PROVIDES AN AVENUE TO ESTABLISH
GOOD DOCTOR-PATIENT RELATIONSHIP
-DURING HISTORY TAKING, THERE ARE CERTAIN
QUESTIONS YOU ASK A PATIENT THAT MAKE HIM/HER
CONCLUDE THAT YOU KNOW WHAT YOU ARE DOING
-SO WHETHER A PATIENT WILL RETAIN YOU AS HIS/HER
DOCTOR (OR FAMILY DOCTOR) WILL DEPEND, TO A
GREAT EXTENT, ON THE QUALITY OF HISTORY TAKEN
DURING YOUR INTERACTION WITH THE PATIENT.
TYPES OF HISTORY:
1) SHORT, BRIEF, FOCUSED HISTORY
- HERE BNOT MUCH DETAILS ARE REQUIRED,
E.G. MASS IN THE NECK, ETC
2) COMPREHENSIVE, DETAILED ,LONG
- LENGTHY HISTORY WHICH REQUIRES DETAILS
- ALL ARE USED IN FINAL MBBS EXAMINATION
• ESSENTIAL ELEMENTS-1:
• -START WITH ESTABLISHING RAPPORT WITH
YOUR PATIENT-HOW?
-PROVIDE COMFORTABLE ENVIRONMENT
(DECENT, CLEAN, CALM ENVIRONMENT, WITH
GOOD CHAIR, VENTILATION)
-PROVIDE PATIENT WITH PRIVACY OTHERWISE
SOME INFORMATION WILL BE HELD BACK BY THE
PATIENT
• IF THEY COME IN GROUP, SEND SOME PEOPLE AWAY
AND STAY WITH THE CLOSEST PERSON TO THE PATIENT
• YOU DON’T TAKE HISTORY IN A CROWDED
ENVIRONMENT
• IF POSSIBLE, ADDRESS PATIENT BY HIS/HER
NAME( FIND OUT HOW A PATIENT MIGHT WANT TO
BE ADDRESSED)
• MAKE PATIENT MORE RELAXED AND CONFIDENT IN
YOU
• EXAMPLE:
• DOCTOR: GODWIN, HOW ARE YOU TODAY?
• GODWIN: DOCTOR, I AM FINE.
• DOCTOR: WHY DO YOU WANT TO SEE US TODAY? OR
IS THERE ANY PROBLEM?
• YOU DON’T ASK A PATIENT : WHAT BROUGHT YOU TO
HOSPITAL TODAY?- THAT REFERS TO MEANS OF
TRANSPORTATION –LIKE KEKE, TAXI
• AND THAT IS NOT WHAT THE PATIENT WANT TO HEAR
• ALLOW PATIENT TO EXPRESS HIMSELF/HERSELF USING
BOTH CLOSED-ENDED AND OPEN-ENDED INTERVIEWING
TECHNIQUES
• USE SIMPLE AND CLEAR LANGUAGE
• THERE MAY BE NEED FOR INTERPRETATION
• AVOID USING CONFUSING ENGLISH OR MEDICAL TERMS
• USE OF BODY LANGUAGE SUCH AS HEAD NODDING,
HAND MOVEMENT, LEANING FORWARD AND BACKWARD;
FACIAL EXPRESSION SUCH AS SMILES, ETC CAN GO
ALONG WAY IN ENCOURAGING PATIENT TO OPEN UP
• INTERVIEWING TECHNIQUES:
1) QUESTIONS
-OPEN-ENDED
-CLOSED-ENDED
-DIRECT
-LEADING
-REFLECTIVE
2) LISTENING AND SILENCE
3)FACILITATION
4)CONFRONTATION
5)EMPATHETIC RESPONSE
6)CLARIFICATION
• ESSENTIALS-2:
-GREET PATIENT AND INTRODUCE
YOURSELF
-EXPLAIN TO PATIENT WHAT YOU WANT TO
DO AND OBTAIN CONSENT
• -KNOW THE PATIENT’S BIODATA
-NAME
-AGE-AUTHENTICATE THE AGE
-SEX
-MARRITAL STATUS
-ADDRESS-LGA, STATE,ETC-VERY IMPORTANT
-OCCUPATION
-RELIGION
-TRIBE/ETHNIC GROUP
-FIND OUT WHERE THE PATIENT IS COMING
FROM—HOME, CHURCH, ANOTHER MEDICAL
FACILITY, NATIVE DOCTOR, POLICE CUSTODY,
STREET, ETC.
-ANY INFORMANT- FOR UNCONSCIOUS PATIENT,
MENTALLY ILL PATIENT, CHILDREN, SPEECH
IMPAIRMENT
• PRESENTING COMPLAINT/CHIEF
COMPLAINT/CHIEF CONCERN:
-SHOULD BE IN PATIENT’S WORDS BUT PROPERLY
FRAMED BY YOU
-CLARIFY IT AND SHOULD BE IN CHRONOLOGICAL
ORDER AND SHOULDN’T BE >4.
• HISTORY OF PRESENTING COMPLAINT/HISTORY
OF PRESENTING ILLNESS
-SHOULD CAPTURE 5C’S
-COMPLAINT
-COURSE OF THE ILLNESS
-CAUSE OF THE ILLNESS
-CARE RECEIVED
-COMPLICATION
• ILLNESS EXPERIENCE OF THE PATIENT:
F-FEAR/FEELING
I-IDEA
F-FUNCTIONAL LOSS
E-EXPECTATION
THE ILLNESS EXPERIENCE OF CHILDREN IS
EXPRESSED BY THE PARENTS/CARE-GIVERS.
• REVIEW OF SYSTEMS
-CNS, CVS, RESPIRATORY, DIGESTIVE/GIT, GUS, MSS
• PAST MEDICAL/SURGICAL HISTORY
-PREVIOUS ILLNESS
-PAST ADMISSION-FOR WHAT?
-PREVIOUS SURGERY
-CHRONIC ILLNESS
-BLOOD TRANSFUSION
• OBSTETRIC/GYNAECOLOGICAL HISTORY( FOR
FEMALE):
-MENARCHE
-LMP, K+M
-PARITY
-CONTRACEPTION
-MENOPAUSE
-POST-MENOPAUSAL ISSUES
• FOR CHILDREN (AFTER PAST MEDICAL
HISTORY):
-PRENATAL HISTORY( PREGNANCY HISTORY
-PERINATAL HX( DELIVERY HX)
-NEONATAL HX-EARLY AND LATE NEONATE
-NUTRITION HX
-IMMUNIZATION HX
-DEVELOPMENTAL MILESTONE
• FAMILY & SOCIAL HISTORY
• THIS IS VERY IMPORTANT IN FAMILY
MEDICINE BECAUSE THE FAMILY AS A
SOCIAL INSTITUTION EXERTS
SIGNIFICANT INFLUENCE ON THE
HEALTH OF AN INDIVIDUAL IN SEVERAL
WAYS
COMPONENTS:
-NUMBER OF SIBLING AND PATIENT’S POSITION
-NUMBER ALIVE/ DEAD
-CAUSE OF DEATH
-PARENTS-ALIVE/DEAD
-CHRONIC ILLNESS IN THE FAMILY
-MARRITAL STATUS-A PATIENT IS EITHER MARRIED OR
SINGLE
-COHABITATION IS NOT MARRIAGE
-NUMBER OF CHILDREN/ THEIR GENDER
-LEVEL OF EDUCATION
-OCCUPATION
-ACCOMMODATION/VENTILATION
-SOURCE OF DRINKING WATER
-AVENUE OF WASTE DISPOSAL
-AVERAGE MONTHLY INCOME
-SUBSTANCE ABUSE-ALCOHOL, TOBACCO, CAFFEINE,
ETC
-SPIRITUALITY
SEXUAL HISTORY:
-VERY IMPORTANT BECAUSE SEXUAL DYSFUNCTION CAN
CAUSE FAMILY DYSFUNCTION – CASCADE OF SEVERAL
OTHER PROBLEMS THAT CAN DISTORT THE DYNAMICS
OF THE FAMILY AND THE SOCIETY AT LARGE
-SEXUAL HISTORY REQUIRES TACT AND EXPERIENCE TO
SUCCEED
-USE NON-JUDGEMENTAL APPROACH FOR EVERY
REVELATION MADE
FIND OUT:
-ANY SEXUAL PROBLEM
-HOW IS YOUR SEXUAL LIFE
-LOSS OF LIBIDO
-POOR ERECTION
-PREMATURE EJACULATION
-HYPERSEXUALITY/HYPERAROSAL
-HYPOSEXUALITY/HYPOAROSAL-ALL CAN AFFECT
QUALITY OF LIFE
DRUG HISTORY:
-ANY ROUTINE DRUGS-- FIND OUT THE NAME
AND THE PURPOSE
-ANY HISTORY OF DRUG ALLERGY?
NOTE:
• AFTER HISTORY, SIGNIFICANT PERCENTAGE OF
INFORMATION FOR DIAGNOSIS MUST HAVE
BEEN MADE
• IN SOME CASES, DEFINITIVE DIAGNOSIS MUST
HAVE BEEN MADE
PHYSICAL EXAMINATION:
• ANOTHER IMPORTANT ASPECT OF
THE PATIENT-DOCTOR
INTERACTION/ENCOUNTER
• CONTRIBUTES SIGNIFICANTLY IN
THE MAKING OF DIAGNOSIS
ESPECIALLY SURGICAL DISEASES
ESSENTIALS:
-EXPLAIN TO THE PATIENT AND OBTAIN CONSENT
(IMPLIED/INFORMED CONSENT)
-BE GENTLE ON PATIENT—CONSIDER MEDICO-
LEGAL IMPLICATION OF WHATEVER YOU DO
WITH PATIENT WHEN THE CHIPS ARE DOWN
(MANY PATIENTS ARE VERY ENLIGHTENED AND
INFORMED)
-EXPOSE WITH RESPECT
-HAVE A CHERPERON WHEN DEALING WITH THE
OPPOSITE SEX ( TO AVOID SCANDAL AND
LITIGATION)
-PATIENT’S PRIVACY IS IMPORTANT EVEN
THOUGH IN THE HOSPITAL
-EXAMINATION COUCH SHOULD BE CLEAN AND
COVERED WITH CLEAN BED SHEET AND
PILLOW CASE
-KNOW HOW TO POSITION YOUR PATIENTS BASED
ON THEIR CLINICAL PRESENTATIONS
-FOWLER’S/CARDIAC POSITION—CARDIAC PATIENT
-LEFT LATERAL DECUBITUS/DORSAL RECUMBENT
(GENUCUBITAL) POSITION– RECTAL
EXAMINATION
-LITHOTHOMY POSITION- PELVIC EXAMINATION
-KNEE-ELBOW POSITION—RECTAL/VAGINAL
-DON’T HURT YOUR PATIENT—AVOID IT AS MUCH
AS POSSIBLE
• AGAIN EXAMINATION COULD BE
- BRIEF, FOCUS
- COMPREHENSIVE OR DETAILED
• PHYSICAL EXAMINATION:
-STARTS BY OBSERVING THE PATIENT AS HE/SHE
WALKS INTO THE CLINIC
-HOW IS THE PATIENT’S APPEARANCE
- APPARENTLY HEALTHY
- ILL
- ACUTELY-ILL—PAIN, FEVER, CONVULSION,
RESTLESS, DEHYDRATED, PALE, DISTRESS, WEAK,ETC
- -CHRONIC—JAUNDICE, WEAK, CYANOTIC, PEDAL
EDEMA, SIGNIFICANT LYMPHADENOPATHY, PALE,
WASTED/CACHETIC, FLUFFY HAIR
- -ACUTE-ON-CHRONIC
-ANTHROPOMETRY
-CHILDREN- OFC, MAC, WT, HT/LENGTH
- COMPARE WITH NORMAL
- FOR ADULT: WT, HT, BMI, WAIST
CIRCUMFERENCE, HIP CIRCUMFERENCE, WHR
- COMPARE WITH NORMAL
• SYSTEMIC EXAMINATION:
-CNS, CVS, RESP., GUS, ABD/GIT, MSS.
• NOTE:
• THE INFORMATION OBTAINED FROM HX AND
EXAMINATION ENABLE THE PHYSICIAN TO FORMULATE
DIAGNOSIS AND TREATMENT PLAN
• IF A DIAGNOSIS CANNOT BE MADE, A WORKING OR
PROVISIONAL DIAGNOSIS MAY BE FORMULATED AND
OTHER POSSIBILITIES (CALLED DIFFERENTIAL
DIAGNOSES) MAY BE ADDED
• AND LISTED IN ORDEROF LIKELIHOOD BY CONVENTION
• AND CONFIRMED WITH DIAGNOSIS.
FACTORS INHIBITING (OR HINDRANCE TO) PROPER HISTORY
MEDICAL HISTORY TAKING:
1) PHYSICAL INABILITY OF THE PATIENT TO COMMUNICATE WITH THE PHYSICIAN
—UNCONSCIOUSNESS, COMMUNICATION/SPEECH DISORDERS, UNDERAGE,
INTOXICATION
SOLUTION-USE CLOSE PERSON TO THE PATIENT TO GIVE THE
HISTORY(heteroanamnesis)
-SOME INFORMATION WILL BE LOST
2)TRANSITION TO PHYSICIANS THAT ARE UNFAMILIAR TO THE
PATIENT
SOLUTION- NEED FOR FOLLOW UP OF PATIENT BY SAME
PHYSICIAN- CONTINUITY OF CARE
3) RELUCTANCE OF PATIENCE TO DISCLOSE INTIMATE OR
UNCOMFORTABLE INFORMATION SUCH AS CASES RELATED
SEXUAL OR REPRODUCTIVE ISSUES (STI, ED, INFERTILITY)
DOMESTIC VIOLENCE/PARTNER ABUSE, ADOLESCENT HEALTH
-PATIENTS USUALLY EXPECT PHYSICIANS TO INITIATE DISCUSSION IN
SUCH AREAS
-SOME PATIENT LEAVE HOSPITAL WITHOUT MENTIONING THEM
SOLUTION: HAVE HIGH INDEX OF SUSPICION ,THERE MAY BE NEED
TO USE CONFRONTATION TO GET THE HISTORY
-CREATE FRIENDLY, APPROACHABLE ATMOSPHERE TO THE PATIENT
AND LET HIM/HER HAVE CONFIDENCE IN YOU.
-
4)CROWDED CONSULTING ROOM-NO PRIVACY
SOLUTION-MAKE CONSULTING ROOM PRIVATE
ENVIRONMENT
5)PHYSICIAN’S UNFRIENDLY ATTITUDE
 ASSIGNMENTS:
1) COMPARE COMPUTER-ASSISTED HISTORY TAKING
VS TRADITIONAL/ORAL WRITTEN HISTORY
2) LOOK OUT FOR MORE CASES WHERE ONLY
HISTORY CAN BE USED TO MAKE DIAGNOSIS
3) WHAT ARE THESE EXAMINATION POSITIONS:
TRENDELEMBURG’S POSITION, PRONE POSITIO,
BORNET POSITION, SIM POSITION.
4) WHAT ARE SICKLE CELL HABITUS? GIVE EXAMPLE.
THANK YOU FOR YOUR
ATTENTION