history and physical exam

1. HISTORY TAKING & PHYSICAL
EXAMINATION
Dr.Bilal Jamal Kamal
MB ChB
FIBMS
MRCP(UK)
Part2

2. HITORY TAKING
Tips for effective conversations:
1. Choose a quiet & private space
2. Speak clearly & audibly
3. Ask open questions to start with
4. Don’t interrupt your patient
5. Try & appear unharried
6. Use silence to encourage explanations
7. Do not use jargon or emotive words
8.Clarify & summarize what you understand
9. Acknowledge emotions
10. Seek ideas, concerns & expectations

3. History taking usually takes 15 min, but for
students, it may take upto 30 min.
Arrange seating in a non-confrontational way.
Look for non-verbal cues e.g. distress & mood.
Active listening:
Hear your patients story, ask open questions to
start with, e.g. What has brought you along to
see me today?
Active listening means encouraging the patient
to talk by looking interested, making
encouraging comments.

4. Closed questions, e.g. Have you had cough
today? Seek specific information as part of a
systemic enquiry. They invite yes or no
answers. Both types of questions have their
places.

5. 1. Demographic data: name, age, gender,
address, marital status, date of addmission
2. Chief complain
3. History of present illness;
Characteristic of pain (SOCRATES)
Site, somatic is well localized, visceral is diffuse
Onset, speed of onset & any associated
circumstances
Character, sharp, dull, burning, stabbing
Radiation

6. Associated symptoms
Timing (duration, course, pattern)
Exacerbating & relieving factors
Severity

7. Past history:
Have you had any serious illness that brought
you to see doctor?
Have you had any operations?
Have you attended any hospital clinics?

8. Drug history
Ask about prescribed drugs, OTC, herbal,
traditional.
Ask about
compliance,adherance,dosage,regimen,durati
on.
DRUG ALLERGIES

9. Family history:
Diseases run in the family??
Social history:
Helps you to understand the context of the patients
life & possible relevant factors.
Lifestyle: exercise, diet, travel history, sexual history,
smooking, alcohol, non-prescribed drugs
Occupation
House
Leisure activities

10. Systemic enquiry
Cardiovascular system: chest pain,breathlessness
Palpitation,leg swelling
Respiratory: cough,dyspnea,sputum,blood in
sputum, chest pain
GIT: mouth, difficulty in swelling,nausea,vomitin
Blood in vomiting,heartburn,bowel motion
Genitourinary: Dysurea,blood in urine,
Frequency, libido
CNS: headache,fits,weakness,visual diturbance
Memory change
Endocrine: heat & cold intolerance, sweating
Musculoskeletal: joint pain, stiffness, mobility
Women: menstrual history

11. PHYSICAL EXAMINATION
• Privacy is essential when you examine a patient
• Talk quietly but ensure good communication
• The room should be warm and well lit
• Subtle abnormalities of complexion such as mild
jaundice are easier to detect in natural light
• cannot lie flat.
• Seek permission and sensitively, but adequately,
expose the areas of the body to be examined;
cover the rest of the patient with a blanket or
sheet to ensure that he or she does not become
cold. Avoid unnecessary exposure and
embarrassment

12. • The sequence of examination is:
• Inspection
• Palpation
• Percussion
• Auscultation

13. Introduce yourself to the patient (Handshake &
first impressions)
History taking from the patient
Differential diagnosis
Examine the patient(General & systemic)
Confirm or refute your diagnosis

14. First Impressions:
The physical examination starts as soon as you see
the patient. Assess patients’ general demeanour
and external appearance, and watch how they
rise from their chair and walk into the room.
The handshake:
Introduce yourself and shake hands. This may
provide diagnostic clues . Greet your patient in a
friendly but professional manner. Note if his right
hand works; in patients with a right hemiparesis
you may need to shake his left hand. Avoid too
firm a grip, particularly in patients with arthritis.

15. Facial expression and general
demeanour:
Actively recognise the features of anxiety, fear,
anger.
Clothing:
Clothing gives clues about personality, state of
mind and social circumstances. Young people
wearing dirty clothes may have problems with
alcohol or drug addiction.

16. Complexion:
Facial colour depends on oxyhaemoglobin, reduced
haemoglobin, melanin and carotene. Unusual
skin colours are due to abnormal pigments.
Haemoglobin: Untanned European skin is pink due
to the red pigment oxyhaemoglobin in the
superficial capillary–venous plexuses. A pale
complexion may be misleading(because it can be
caused by vasoconstriction during faint or fear)
but can suggest anaemia. The pallor of anaemia is
best seen in the mucous membranes of the
conjunctivae, lips and tongue and in the nail
beds. Facial plethora is caused by raised
haemoglobin concentration with elevated
haematocrit (polycythaemia).

17. Cyanosis:
Cyanosis is a blue discoloration of the skin and
mucous membranes that occurs when the
absolute concentration of deoxygenated
haemoglobin is increased.
• Central cyanosis
• Central cyanosis of the lips.This is seen at the
lips and tongue . It corresponds to an arterial
oxygen saturation (SpO2) of <90% and usually
indicates underlying cardiac or pulmonary ot
due to increment of deoxygenated Hb > 5 g/dl

18. • Peripheral cyanosis
This occurs in the hands, feet or ears, usually
when they are cold. In healthy people it occurs
in cold conditions when prolonged peripheral
capillary flow allows greater oxygen extraction
and hence increased levels of
deoxyhaemoglobin. In combination with
central cyanosis, it is most often seen with
poor peripheral circulation due to shock, heart
failure.

19. • Melanin
Causes of abnormal melanin productionSkin
colour is greatly influenced by the deposition
of melanin.
Vitiligo:
This chronic condition produces bilateral
symmetrical depigmentation, commonly of
the face, neck and extensor aspects of the
limbs, resulting in irregular pale patches of
skin.
Albinism:
This is an inherited disorder in which patients
have little or no melanin in their skin or hair

20. • Overproduction of melanin
This can be due to excess of the pituitary
hormone, adrenocorticotrophic hormone, as
in adrenal insufficiency
• Pregnancy and oral contraceptives
These may produce chloasma (blotchy
pigmentation of the face)

21. Carotene: Hypercarotenaemia occurs in people
who eat large amounts of raw carrots and
tomatoes, and in hypothyroidism. A yellowish
discoloration is seen on the face, palms and
soles, but not the sclerae, and this
distinguishes it from jaundice
Bilirubin: Jaundice is detectable when serum
bilirubin concentration is elevated and the
sclerae, mucous membranes and skin become
yellow.
Iron: Haemochromatosis increases skin
pigmentation due to iron deposition and
increased melanin production

22. m

25. The Hands:
Examination sequence:
■ Inspect the dorsal and then palmar aspects of
both hands.
■ Note changes in the:
■ skin
■ nails
■ soft tissues (evidence of muscle wasting)
■ tendons
■joints.
■ Feel the temperature.

26. Abnormal findings :
Deformity
Colour
Temperature
Skin
Finger clubbing Clubbing: is painless soft-tissue
swelling of the terminal phalanges. The
enlargement increases convexity of the nail
with loss of nail fold angle.

27. Cause of finger clubbing:
Lung diseses: abscess, bronchiectasis, fibrosis
Heart diseases: cyanotic congenital heart
disease, Infective endocarditis
GIT: Cirrhosis , IBD, Celiac disease

30. THE TONGUE:
Examination sequence :
Ask the patient to put out his tongue.
Look at the size, shape, movements, colour and
surface
THE LYMPH NODES :
Lymph nodes may be palpable in normal people,
especially in the submandibular, axilla and groin
regions . Distinguish between normal and
pathological nodes. Pathological
lymphadenopathy may be local or generalised,
and is of diagnostic and prognostic significance in
the staging of lymphoproliferative and other
malignancies.