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Introduction History

This document provides a framework for taking a patient's physical examination history. It outlines the key areas to cover, including: obtaining consent and basic details; presenting complaint; history of presenting complaint; review of symptoms in major body systems; past medical history; family history; social history; current medications and drug allergies. The goal is to gather a comprehensive yet concise medical history through open-ended questions to understand the patient's condition and how it affects their daily life.

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Ayro Business Center
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© © All Rights Reserved
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Download as PPTX, PDF, TXT or read online on Scribd
58 views

Introduction History

This document provides a framework for taking a patient's physical examination history. It outlines the key areas to cover, including: obtaining consent and basic details; presenting complaint; history of presenting complaint; review of symptoms in major body systems; past medical history; family history; social history; current medications and drug allergies. The goal is to gather a comprehensive yet concise medical history through open-ended questions to understand the patient's condition and how it affects their daily life.

Uploaded by

Ayro Business Center
Copyright
© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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PHYSICAL EXAMINATION

History Taking Framework


INTRODUCTION:
• Remember to introduce yourself, wear your name badge and
state the purpose of the interview and approximate time
needed.
• What the patient will be discussing with you may be very
personal to them, so remember to stress that the interview is
confidential.
• ask for their consent.
• However, you and the patient can agree that parts of the
history can stay completely confidential between you.
• Try to be aware of basic details such as name and age before
you meet the patient.
CONT…
• Confirm with them their name, age and
occupation.
• This may give you valuable information which
can help with diagnosis and management.
• Remember to ask retired patients their
previous occupations.
Presenting Complaint

• This is the opening question. Remember, it is


important to start with an open question.
• Try a variety of questions and see which you prefer.
Your choice may depend on the circumstances of the
interview. Some options include:
• What has the problem been?
• What made you go to the doctor?
• Can you tell me the background to how you came to be in
hospital?
History of Presenting Complaint (HPC)

• This is the main part of the history and you


will need to spend time discussing this with
the patient.
• There are two parts to the HPC:-
1. A description and exploration of the patient’s
problem
2. How the problem affects the patients
personally
1. A Description and exploration of the patient’s problems

• You can start with: “Can you tell me more about your
problem?”
• Allow the patient to tell you in his or her words; this can take
a couple of minutes of uninterrupted talk from the patient.
• They are likely to need verbal and non-verbal encouragement
from you to maintain the flow.
• You can gain a great deal of information during this time:
• Observe the patient – do they appear anxious, depressed?
CONT…….
Asking about symptoms can follow a similar line of questioning:
• When did the problem start?
• Is it a new or old problem?
• What did it feel like?
• How often does it occur?
• How long does it last?
• What makes is worse?
• What makes it better?
• Does anything else happen to you at the same time, before or
after?
CONT…..
• Questions about pain should cover the following points:
• Site where is the pain?
• Radiation Does the pain go anywhere else?
• Character What’s the pain like?
• (Think colicky, constant, dull, sharp, gripping etc)
• SeverityHow severe is the pain?
• Does it wake you at night?
• Does it stop you doing what you are doing at the time?
• Timing How long does it last?
• How often does it occur?
• Association Does it come with any other symptoms?
• Are there any precipitating or relieving factors?
• You will learn more about how to direct your line of questioning on your clinical
firms throughout the course.
 
2.How the problem affects the patient personally

• This should not be forgotten!


• This also connects with the assessment of mental state,
particularly inquiring about symptoms of depression.
• You can ask:
* How has this illness affected you generally?
* How does this make you feel overall?
Remember to acknowledge how the patient feels. We
know it is common sense, but it’s amazing how often
this is forgotten.
REVIEW OF SYSTEMS.

• As illnesses affect different parts of the body,


and many illnesses may be multi-system, it is
important to ask about connected symptoms.
• More specific questions may need to be asked,
remember to ask them without using medical
jargon. For example, when asking about rectal
bleeding, you can ask:
• Have you ever passed any blood with your
stools?
CONT…..
• You need to cover the following areas:
• Respiratory Systems: Dyspnoea, cough, sputum, haemoptysis, chest pain
• Cardiovascular Systems: Chest pain, orthopnoea, dyspnoea, ankle
swelling, palpitations.
• Gastrointestinal System: Abdominal pain, nausea, vomiting,
haematemesis, bowel habit, melaena.
• Urogenital System: frequency, nocturia, polydypsia, loin pain,
haematuria
• Menarche, menopause, cycle, intermenstrual bleeding,
• Central Nervous Systems: Headaches, visual disturbances, sleep,
hearing, light headedness, unsteady gait, weakness and parasthesiae
• Musculoskeletal: Myalgia, arthralgia, back pain, joint swelling
Past Medical and surgical History (PMH)

• Always ask the patient if they have or have had any serious
illnesses. The precise details will depend on the clinical
condition and the circumstances.
• Include:
*Operations
*Hospital admissions
• Ask specifically about hypertension, Ischaemic Heart Disease,
strokes or , Diabetes, asthma, jaundice, TB, Rheumatic Fever
 
Family History (FH)

• This gives a clue to any predisposition to any illnesses and may


highlight specific concerns the patient may have about a certain
disease. 
• You could ask:-
*Are your parents alive or have they died?
*Are there any diseases running through the family?
•  
• Ask the patient what their parent(s) died from and at what age.
If they have died, be sensitive to how the patient may feel about
this. It is always important to acknowledge a death. You can say:
*I am very sorry to hear that, it must have been very upsetting*
Social History (SH)

 
* This is a very important part of the patient’s
history. It provides information about:
• The patient as a person
• How the illness affects the patient and their
family
CONT……
• Questions you can ask include:
• How are things at home?
• Who is at home?
• Are there any problems at home?
•  
• Remember to ask about:
• Job
• Hobbies
• Social Life
• Diet
• Alcohol
• Smoking
CONT…..

• Asking about alcohol and drug use can


sometimes be difficult. It is easier to be very
open and straight-forward. You can just ask:
• Do you drink alcohol?
• If yes, how much a day?
• Do you use any recreational drugs?
Drug History

• List of all patients’ drugs and doses. Remember


over the counter and alternative medicines.
Some patients can be quite vague about their
tablets-try and persevere.
• Try to assess compliance:
• What problems do you have with your
medicines?
• Do any of your medicines give you side effects?
Drug allergy

• Identify any drug allergies the patient may have, and details of
what happens, for example, rash or anaphylaxis
• Review
• It is always useful to summarise the history and main points back
to the patient. It ensures that the patient and you agree and
often stimulates the patient to remember other important facts.
•  
• Summary
• At the end of presenting a history you will often be asked to give
a summary.
Summary of History

• Summary of History
• Introduction
• Name, age, occupation
• Presenting complaint
• History of presenting complaint(HPC)
• Systemic enquiry
• Past medical history (PMH)
• Family history (FH)
• Social history (SH)
• Drug history
• Drug allergies
• Review
• Summary

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