HISTORY TAKING

Alrik Earle T. EscuderoHISTORY TAKINGSIGNIFICANCEObtaining an accurate history is the critical FIRST STEP in determining the ETIOLOGY of a patients problemA large percentage of the time (70%), one will be able to make a diagnosis on history aloneGeneral ApproachIntroduce YourselfTry and See things from patients point of view.Understand patient underneath mental status, anxiety, irritation or depressionAlways exhibit neutral positionListen CarefullyQuestioning: simple, clear avoid medical terms, use open leading questionsGeneral DataNameAgeAddressSexEthnicityOccupationReligionMarital StatusDate of ExaminationComplete History Chief ComplaintHistory of Present IllnessPast Medical/Surgical HistoryFamily HistoryPersonal/Social HistoryMenstrual HistorySexual HistoryObstetrical HistoryReview of Systems

Chief ComplaintWhy did the patient seek care?History of Present Illness1. Complete description of first symptoms Provokes causative, relieving, exacerbating factors Quality Pain: sharp, dull, stabbing, burning, crushing Radiates Primary location Area where it radiates Localization Severity (0 10)/Intensity/Progression Time Onset Duration Persistence Number of occurences2. Medications (include dosage)3. Results of previous laboratory work-up4. Results of previous ancillary procedures5. State of health just before onset of problem6. What led the patient to seek consult?Past Medical History1. Illnesses Hypertension Allergy Gout/arthritides Heart disease Asthma Stroke Diabetes mellitus Tuberculosis Seizures Thyroid disease Blood dyscrasias Cancer2. Allergies Food Environmental exposures Adverse drug reactions3. Medications Current Frequently Herbal4. Previous hospital admission5. Previous injury6. Previous surgery7. Previous blood transfusionFamily History1. Allergy2. Asthma3. Tuberculosis4. Gout/Other arthritides5. Blood dyscrasias6. Cancer7. Diabetes mellitus8. Heart diseases9. Hypertension10. Stroke11. Mental illness12. OthersPersonal And Social History1. Habits Smoking history Alcohol Substance use/abuse2. Nutrition Diet Source of water3. Sleep pattern4. Exercise5. Living arrangement6. Source of income7. Support systemMENSTRUAL HISTORY1. Menarche age/Menopause age2. Menstrual flow Interval Duration Amount Symptom (Dysmenorrhea)3. LMP4. PMPSexual History1. Coitarche2. # of sexual partners3. Symptoms (Dyspareunia, post coital bleeding)Obstetrical History1. Obstetrical scoreGravidity, ParityTerm, Preterm, Abortion, Living2. Details of previous pregnancyYear, manner, and outcome of delivery3. Family planning method/s4. Prenatal check-ups for current pregnancyReview of SystemsGENERAL:(-) weakness, (-) fatigue, (-) febrile (-) weight gain/lossSKIN: (-) pruritus, (-) dry skin, (-) bruises, (-) rash, (-) photosensitivityEAR: (-) deafness, (-) tinnitus, (-) dischargeNOSE: (-) epistaxis, (-)discharge, (-) obstruction, (-) post-nasal drip, (-) sinusitisMOUTH: (-) bleeding gums, (-) sores, (-) fissures,(-) tongue abnormalities, (-) dental cariesTHROAT: (-) soreness, (-)tonsillitisNECK:No stiffness, limitation of motion, masses, (-) sensation of lump in throat BREAST: No masses, discharge, traumaPULMONARY: (-) dyspnea, no cough, sputum production, hemoptysis, wheezing, chest wall abnormalityReview of SystemsCARDIOVASCULAR: No chest pain, (-) PND, (-) orthopnea, (-) syncope, (-) edema, (-) phlebitis, no varicosities, claudicationGENITOURINARY: (-) hematuria, dysuria, bubbly urine, flank pain Musculoskeletal: (-)pain, (-) weakness in lower extremities, wasting, trauma, abnormal postureEndocrine: No heat or cold intolerance, voice change, polyuria, polyphagia, polydypsiaHematopoietic:(-) Easy bruisability, pallor, no adenopathy, no gum bleedingNeurologic: No headache, seizure, sensory perversion, motor dysfunction, speech disturbance, mental changes, head traumaPsychiatry: No anxiety, depression, interpersonal relationship difficulties, illusion, delusion, hallucination, paranoia Alrik Earle T. EscuderoPHYSICAL EXAMINATIONGeneral SurveyGeneral appearance, posture (relaxed, rigid, restless), groomingDescribe general state of health (well, acutely ill or chronically ill)Level of comfort Comfortable or in distress Distress: speaks in phrases, tripod, orthopnea, squattingLevel of consciousness (Conscious, sedated, drowsy)Ambulatory status (Ambulatory/with assistance/Wheelchair/Bedridden)Body habitus Hyposthenic/ectomorphic Sthenic/mesomorphic Hypersthenic/endomorphicFacies Moon facies Stare of hyperthyroidVital SignsBlood PressureProper measurement of sphygmomanometerWidth = 40% of upper arm circumference (12 to 14 cm)Length = 80% of upper arm circumferenceApply cuff 2.5 cm above the antecubital fossaSlowly deflate the cup by 2 to 3 mmHg/second. State the reading on the manometer when the first Korotkoff sound is heard as the auscultatory systolic BP. Continue to deflate slowly by 2 to 3 mmHg/second and note level on the manometer when Korotkoff sound disappears as the diastolic BP (phase 5).Classification of blood pressure:Heart RateRespiratory RateTemperaturePain Scale

Vital SignsHeart RateUse index and middle fingers to palpate for radial artery pulse.Count pulse rate for one full minute.Note rhythm: regular or irregular. Note volume.Respiratory Rate (Note number of rise/fall (cycles) of the vest for 1 full minute) Normal: regular and comfortable at a rate of 12 to 20 per minute. Bradypnea: < 12 breaths/minute vs. Tachypnea: > 20 breaths/minuteTemperaturePain Scale

AnthropometricsBMI = Weight in kilograms/(Height in meters)2

Exam of the SkinExamine the patient in good lighting Inspect and palpate skin for the following: ColorTexture TurgorMoisture Pigmentation Lesions Hair distribution Warmth: use back of hand

21Abnormal FindingsColor Pallor: Iron def. anemiaYellow: JaundiceCarotenemiaHemolysisRed: ErythrodermaPigmentation Hyper pigmentation Localized: PregnancyBCP ingestionGeneralized:ThyrotoxicosisLiver diseaseRenal disease De-pigmentation:VitiligoInjury

22Abnormal FindingsTexture Soft: (Thyrotoxicosis) Tight: (Scleroderma) Rough: (Hypothyroidism) Moisture Dry: (Vitamin A def, Myxedema) Oily: (Acne)

Turgor Decreased: (Dehydration) Warmth: Generalized warmth: (Fever, Hyperthyroidism) Localized warmth: (Inflammation) Coolness: (Hypothyroidism, Frostbite, Hypothermia, Shock, Low cardiac output)

23MOLE WARNING SIGNS The "ABCD" rule & Melanoma Danger Signs

Asymmetry Unequal or asymmetric moles are suspicious.

25BorderIf the border is irregular or indistinct, it is more likely to be cancerous (or precancerous)

26ColorVariation of color (e.g., more than one color or shade) within a mole is a suspicious finding

27DiameterAny mole that has a diameter larger than a pencil's eraser in size (> 6 mm) should be considered suspicious.

28ElevationIf a mole is elevated, or raised from of the skin, it should be considered suspicious

HEENTHead and ScalpNote hair color, quantity, distribution, and texture.Note presence of seborrhea or lesions.Eyebrows note symmetry, loss/extraordinary hair growth, presence of seborrheaEyelids note symmetry, matting or loss, crusting, redness, swellingEyes note position, alignment, symmetry, size, shapeConjunctivae and Sclera Instruct patient to look up. Pull down lower lid of each eye to expose inferior sclera and conjunctiva. Using a penlight, inspect sclera and conjunctiva of upper eyeball for color,vascularity, and swelling. Do the same for the other eye.Tests pupils for reactivity to light, both direct and consensual as well as accommodation

EarInspect and palpate external ear for deformities, tenderness.Inspect for wax, discharge, foreign bodies, redness, and swelling. Inspect tympanic membrane for the following, note normal findings:Color: transluscent, pearly gray color Landmarks: umbo, handle of malleus, light reflexContour: slightly conical with concavity at the umboPerforations: noneNoseVisually inspect and palpate nose for deformity, symmetry, inflammation.Elevate tip of nose with neck hyperextended.Bilaterally inspect nasal mucosa.Inspect nasal septum.MouthInspects lips, gums, teeth, tongue, floor ofthe mouth, and posterior pharynx.Instruct patient to open mouth.With tongue blade and penlight visually inspect hard and soft palate, buccal mucosa, gingiva, teeth, and tongue.Lymph Node PalpationPalpate with pads of all four fingertipsExamine both sides simultaneouslyUse steady gentle pressureThe major lymph node groups are located along the anterior and posterior aspects of the neck and on the underside of the jaw

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Cervical Nodes

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36Exam of Lymph NodesLymph nodes are part of immune systemLymphadenitisFirmTenderEnlargedWarmMay remain enlarged after infectionLess than 1 cmNontender37MalignanciesFirmNon-tenderMatted (i.e. stuck to each other)Fixed (i.e. stuck to underlying tissueIncrease in size over time38Common Causes of LymphadenitisPharyngitis or dental infectionsDiffuse upper airway infectionsMononucleosisSystemic infectionsTuberculosisInflammatory processesSarcoidosis39Examination of the Thyroid

40InspectionGland lies approximately 2-3 cm below the thyroid cartilageEither side of the tracheal rings, which may or may not be apparent on visual inspection.

41Palpation Stand behind the patient and place the middle three fingers of both hands along the mid-line of the neck, just below the chin identify and feel the structures from the front before performing the exam from behindSlide the three fingers of both hands to either side of the rings Have the patient drink water as you palpate

42If enlarged, is it symmetricalUnilateral vs. bilateralDiscrete nodules within either lobe? Gland feels firmis it attached to the adjacent structures? (i.e. fixed to underlying tissue.. consistent with malignancy) freely mobile? (i.e. moves up and down with swallowing)

43Findings of Exam of ThyroidConsistency of glandConsistency of muscle tissueUnusual hardnessCancer or scarringSoftness, or sponginessToxic goiterTendernessAcute infectionsHemorrhage into the gland44ANTERIOR THORAX, LUNGSAssesses symmetry of lung expansion(inspection and palpation).Palpates for any tenderness in the chest wall and performs tactile fremiti.Percusses anterior lung fields.Auscultates anterior lung fields.Use diaphragm of stethoscope.Note: vesicular, bronchovesicular, broncho-trachealJVP and Carotid PulseInspects neck veins and identifies highest undulation of the right internal jugular vein and measures JVP at 30 or 45 degree angle.Palpates for carotid artery pulse (one at a time) and describes.Note: Amplitude: 0 = absent, +1 = diminished, +2 = normal, +3 = full, increased, +4 =boundingContour: normal = smooth, rounded, domedUpstroke and downstrokeCardiovascularInspects precordium and reports its dynamicity (adynamic, dynamic, hyperdynamic)Palpates precordium and describes apex beat (location, diameter, amplitude, duration in relation to systole)Palpates for LV or RV heaves, LA or RA lifts, abnormal pulsations over 2nd ISC RPSL, and thrills.Mitral valve: apex beat (5th ICS), LMCLTricuspid valve: left lower sternumPulmonic valve: 2nd ICS LPSL Aortic valve: 2nd ICS RPSL

Heaves: Using heel of the right hand palpate for abnormally strong pulsation (left ventricular heave) or over the area of the apex beat Using the heel of the right hand palpate for abnormally strong pulsation (rightventricular heave) over the left side of the lower sternum Lifts: Using fingertips, palpate for abnormal pulsation over the 2nd ICS RPSL for aorticartery dilation Using fingertips, palpate for abnormal pulsation over the 3rd and 4th ICS LPSL for leftatrial lift Thrills: Using ball of the hand feel for fine vibratory sensations over the different clinical

47Examination of the Abdomen48General ConsiderationsPatient should have an empty bladder. Supine on the exam table and appropriately draped. Examination room must be quiet to perform adequate auscultation and percussion. Watch the patient's face for signs of discomfort during the examination 49Disorders in the chest will often manifest with abdominal symptoms

It is always wise to examine the chest when evaluating an abdominal complaint

Inguinal/rectal examination in malesPelvic/rectal examination in females50Anatomical Locations

52InspectionScars, striae, hernias, vascular changes, lesions, or rashes Movement associated with peristalsis or pulsationsAbdominal contourFlat, scaphoid, or protuberant? 53AuscultationPlace the diaphragm of stethoscope lightly on the abdomenListen for bowel soundsnormalincreaseddecreasedabsent

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Listen for bruits over the renal arteries, iliac arteries, and aortaPercussionPercuss in all four quadrants Categorize what you hear as tympanic or dull. Tympany is normally present over most of the abdomen in the supine position. Unusual dullness may bea clue to an underlying abdominal mass

56Liver SpanPercuss downward from the chest in the right midclavicular line to detect the top edge of liver dullness. Percuss upward from the abdomen in the same line to detect the bottom edge of liver dullness. Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult.

57Splenic DullnessPercuss the lowest costal interspace in the left anterior axillary lineThis area is normally tympanic. Ask the patient to take a deep breath and percuss this area againDullness in this area is a sign of splenic enlargement.

58General PalpationLight palpationAreas of tendernessMost sensitive indicator is patients facial expressionWatch the patients face, not your handsVoluntary or involuntary guarding may be presentDeep PalpationIdentify abdominal masses or areas of deep tenderness

59Palpation of the LiverPlace the fingers just below the right costal margin and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against your fingersOr it may slide under your hand as the patient exhales. A normal liver is not tender

60Palpation of the AortaPress down deeply in the midline above the umbilicusThe aortic pulsation is easily felt on most individualsA well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.

61Palpation of the SpleenUse the left hand (posteriorly) to lift the lower rib cage and flank Press down just below the left costal margin with the right handAsk the patient to take a deep breathThe spleen is not normally palpable on most individualSpecial

TestsRebound TendernessTest for peritoneal irritationWarn the patient Press deeply on the abdomenAfter a moment, quickly release pressure If it hurts more upon release, the patient has rebound tenderness

64+CVA is associated with renal diseaseWarn the patient what you are about to doHave the patient sit up on the exam table Use heel of your closed fist tostrike the patient firmly over costovertebral anglesCompare the left and right sides

Costovertebral Tenderness65Test for peritoneal fluid (ascites)Percuss the abdomen to outline areas of dullness and tympanyHave the patient roll away from you Percuss again If dullness has shifted to areas of prior tympany, patient may have excess peritoneal fluid

Shifting Dullness66Have patient lie on left sidePlace your left hand on patients right hipExtend the right thigh while applying counter resistanceIncreased abdominal pain indicates a positive psoas sign

Psoas Sign67Raise the patient's right leg with the knee flexedRotate the leg internally at the hipIncreased abdominal pain indicates a positive obturator sign

Obturator Sign

68Murphy SignPlace palpating fingers beneath the right costal arch just below the hepatic marginAsk the patient to take a deep breathWhile patient is inhaling, press fingers deeply beneath the arch Interruption of inhalation = positive Murphys sign = Cholecystitis (RUQ)Rectal ExaminationInspect perianal area for skin tag, lesions, external hemorrhoids, lumps, opening of fistula.Perform digital examination:Wear gloves on right hand and lubricate index fingerInsert lubricated finger gently into the anal canal pointing toward the umbilicusNote for anal sphincteric tonePalpate anus on 4 quadrants and note for: mass, tenderness, internal hemorrhoids,prostate size, consistency, tenderness, nodule, cervix, blood on examining fingerTHANK YOU!