Tally and O’Connor’s Clinical Examination

(8th Edition, Volume 1)

Notes & Summaries by Yasin Kadri

 Section 1
The general principles of history taking &
physical examination
Chapter 1
The general principles of history taking

In obtaining patient’s history, allow the patient to tell the story first and avoid almost the
overwhelming urge to interrupt.
Start with open-ended question to let the patient to share his/her story, then ask specific
questions to fill in the gaps.
While taking notes, let the patient know that you will be listening to them.
The final record must be a Sequential, accurate account of the development and course of
the illness or illnesses of the patient.
In order to obtain a thorough history the clinician must establish a good relationship,
interview in a logical manner, listen carefully, interrupt appropriately and usually only after
allowing the patient to tell the initial Storey, note non-verbal clues and correctly interpret
the information obtained.
- What has been the trouble recently?
- When were you last quite well?
- What made you come to the hospital/clinic today?
For a follow-up consultation, some reference to the last visit is appropriate, for example:
- How have things been going since I saw you last?
- It's been about... weeks since I saw you last, isn't it?
- What has been happening since then?
When a patient stops volunteering information, the question “What else?” will usually help
stat the conversation again and can be repeated several times if necessary.
It is necessary to ask specific question to test diagnostic hypothesis.
If the patient stops giving the Storey spontaneously it can be useful to provide a short
summary of what has already been said and encourage him or her to continue.
Patients’ descriptions of their systems may vary as they are subjected to repeated
questioning by increasingly senior medical staff. The patient who has described his chest
pain a sharp and left sided to the medical students may tell you were registrar that the pain
is dull and in the centre of his chest. These discrepancies come as no surprise to experienced
clinicians; they are sometimes a result of the patient having had time to reflect on his or her
symptoms. This does mean, however, that very important aspects of the story should be
checked by asking follow up questions, such as call an “can you show me exactly where the
pain is?” and “what do you mean by sharp pain?”

Presenting (Principal) Symptom

Whenever you identify a major complaint or symptom, think of the following as you are
trying to unravel the story and ask questions to try to find out:
1. where is the problem? (probable anatomical diagnosis)
2. what is the nature of the symptom? (likely pathological diagnosis)
3. how does it affect the patient? (physiological and functional diagnosis)
4. why did the patient develop it? (etiological diagnosis)
A diagnosis is not just about a name; You are trying to determine the likely disease process
so that you can advise the patient of the prognosis and plan management.

History of The Presenting Illness

When writing down the history of the presenting illness, the events should be placed in
chronological order; This might have to be done later when the whole story has been
obtained. If numerous systems are affected, the events should be placed in a chronological
order for each system. Remember, patients may have multiple problems, of which some are
interdependent and some not. In the older person, multiple problems are the rule, not the
exception.
SOCRATES
SITE
Ask where the symptom is exactly and whether it is localized or diffused. As the patient to
point to the actual site on the body.
ONSET (mode of onset and pattern)
1. Find out whether the symptom came on rapidly, gradually or instantaneously .
2. ask whether the symptom has been present continuously or intermittently.
3. find out whether the symptom is getting worse or better, and, if so, when the change
occurred .
4. find out what the patient was doing at the time the symptoms began.
Character
Here it is necessary to ask the patient what is meant by the symptom, to describe its
character.
If there is pain, is it sharp, dull, stabbing, boring, burning or cramp-like?
Radiation of pain or discomfort
Determine whether the symptom, if localized, radiates; This mainly applies if the symptom is
pain. Certain patterns of radiation are typical of a condition or even diagnostic.
Alleviating factors
Ask whether anything makes a symptom better. Have analgesic medications been used to
control the pain? Have narcotics been required?
Timing
Find out when the symptoms first began and try to date this as accurately as possible. For
example ask the patient:
What the first thing was that he or she noticed was “unusual” or “wrong”.
Ask whether the patient has had a similar illness in the past.
It is often helpful to ask patients when they last fell entirely well.
In a patient with longstanding-symptoms, ask why he or she decided to see the doctor at
this time.
Exacerbating factors
ask whether anything makes the symptom worse.
Severity
This is subjective. The best way to assess severity is to ask the patient whether the symptom
interferes with normal activities or sleep. Severity can be graded from mild to very severe. A
mild symptom can be ignored by the patient, whereas a moderate symptom cannot be
ignored but does not interfere with the daily activities. A severe symptom interferes with
daily activities, whereas a very severe symptom markedly interferes with most activities.
Alternatively, pain or discomfort can be graded on a 10-dash point scale from zero (no
discomfort) to 10 (unbearable).
A face scale using pictures of difference faces to represent pain severity from no pain (0) to
very much pain (10) can be useful in practice.
Other methods of quantifying pain are available, the Visual Analogue Scale, whereby the
patient is asked to mark the severity of pain on a 10-centimetre horizontal line.
It is relevant to quantify the severity of each symptom — but also to remember that
symptoms that a patient considers mild may be very significant.
 Associated Symptoms
Cardiovascular System
Have you had any pain or pressure in your chest, neck or arm? (myocardial ischaemia)
have you ever woken up at night short of breath? (cardiac failure)
Have you had blackouts without warning? (Stokes—Adams attacks)
Have you felt dizzy or blacked out when exercising? (severe I ortak stenosis or hypertrophic
cardiomyopathy)
Respiratory System
Are you ever short of breath? Has this come on suddenly? (pulmonary embolism)
Is your cough associated with shivers and shakes (rigors) and breathlessness and chest pain?
(pneumonia)
have you coughed up blood? (bronchial carcinoma)
What type of work have you done? (occupational lung disease)
Gastrointestinal System
Have you had any difficulty swallowing? (esophageal cancer)
Have you had vomiting, or vomited blood? (gastrointestinal bleeding)
Have your bowel habits changed recently? (carcinoma of the colon)
Have you lost control of your bowels or had accidents? (fecal incontinence)
Have you seen blood in your emotions? (gastrointestinal bleeding)
Have your bowel motions been black? (gastrointestinal bleeding)
Have you lost weight recently without dieting? (malignancy)
Tell me (briefly about your diet recently.
Genitourinary System
Is there a delay before you start to pass urine? (applies mostly to men)
Have you seen blood in your urine? (urinary tract malignancy)
Haematological System
Have you had fevers, or shivers and shakes (rigors)?
Do you have difficulty stopping a small cut from bleeding? (leading disorder)
Have you noticed any lumps under your arms, or in your neck or groin? (haematological
malignancy)
Musculoskeletal System
Do you have painful or stiff joints?
Are any of your joints red, swollen and painful?
Do you have any back or neck pain?
Do your fingers ever become painful and become white and blue in the cold? (Raynaud’s )
Endocrine System
Have you noticed any swelling in your neck?
Have you had a thyroid problem or diabetes?
Have you been troubled by fatigue?
Have you been unusually thirsty lately? Or lost weight? (new onset of diabetes)
Reproductive & Breast History (Women)
Are your periods regular?
Do you have excessive pain or bleeding with your periods?
How many pregnancies have you had?
Have you had any miscarriages?
Have you had high blood pressure or diabetes in pregnancy?
Were there any other complications during your pregnancies or deliveries?
Have you had a cesarean section?
Have you had any bleeding or discharge from your breasts or felt any lumps there?
(carcinoma of the breast)
Neurological System and Mental State
Do you get headaches?
Is your headache very severe and did it begin very suddenly? (subarachnoid hemorrhage)
Have you had fainting episodes, fits or blackouts?
Have you had weakness, numbness or clumsiness in your arms or legs?
Have you ever had a stroke or head injury?
The Elderly Patient
Have you had a problem with falls or loss of balance? (high fracture risk)
Do you take sleeping tablets or sedatives? (falls risk)
Do you take blood pressure tablets? (postural hypotension and falls risk)
Have you had problems with your memory or with managing things like paying bills?
(cognitive decline)
How do you manage your various tablets? (risk of polypharmacy and confusion of doses)
Concluding the interview
Is there anything else you would like to talk about?
 The effect of the illness
Even after full recovery from a life-threatening illness, some people may be
permanently affected by loss of confidence or self-esteem. There may be continuing
anxieties about the capability of supporting a family.
Try to find out how the patient and his or her family have been affected.
How has the patient coped so far, and what are the expectations and hopes for the
future with regard to health?
What explanations of the condition has the patient been iven or obtained (e.g from
the internet)?

DRUG AND TREATMENT HISTORY

Ask the patient whether he or she is currently taking any tablets or medicines. (the
use of word “drug” may cause alarm).
Ask the patient to show you all his or her medications, if possible and list them. Note
the dose, length of use, indication for each drug and any side effects.
This drug list may provide a useful clue to chronic or past illnesses.
Ask whether the drugs were taken as prescribed.
Always ask specifically whether a woman is taking the contraceptive pill, because
many who take it do not consider it a medicine or tablet. The same is true of inhalers.
Also ask whether the patient is taking any over the counter preparations (aspirin,
antihistamines,vitamins).
Ask about each drug on the list, whether it is still beign taken and what it is for.
Note any adverse reactions in the past.
Also ask specifically about any allergy to drugs (often a skin reaction or episode of
bronchospasm). Patients often confuse an allergy with a side effect of a drug.
Approximately, 50% of people now use “natural remedies” of various types. They do
not feel that these are a relevant part of their medical history, but these chemicals,
like any drug, may have adverse effects.
Ask (where relevant) about “recreational drugs” or street drug use (vide infra).
Not all medical problems are treated with drugs. Ask about courses of physiotherapy
or rehabilitation for musculoskeletal problems or injuries, or to help recovery
following surgery or a severe illness.
 Past History
Some patients may feel that questions about past problems and the more general
questions asked in the systems review are somewhat intrusive. It may be best to
practice questions by saying something like, “I need to ask you some questions
about your past medical problems and general health. These may affect your current
investigations and treatment.”
Ask the patient whether he or she has had any serious illnesses, including any
obstetric or gynaecological problems.
Do not forget to enquire about childhood illnesses.
Ask about past blood transfusion (including when and what for).
 Magnetic metals especially most cardiac pacemakers are a contraindication to
magnetic resonance imaging (MRI)
 Chronic kidney disease (CKD ) maybe a contraindication to X Rays using
iodine contrast and materials and MRI scan in using gadolinium contrast .
 Pregnancy is usually a contraindication to radiation exposure (xrays and
nuclear scans - remember that computed tomograpy (CT) scans cause
hundreds of times the radiation exposure of simple xrays).
The patient may believe that he or she has had a particular diagnosis made in the
past but careful questioning may reveal this as unlikely.
The mature clinician needs to maintain an objective skepticism about the information
that is obtained from the patient.
Patients With chronic illnesses may have had their condition managed with the help
of various doctors and that specialized clinics . Find out what supervision and
treatment these have provided. For example, who does the patient contact if there is
a problem with the insulin dose, and does the patient know what to do (an action
plan) if there is an urgent or a dangerous complication?
It should be routing to find out whether the adult patient is up to date with the
recommended immunizations (mumps, measles, rubella, tetanus, etc.) as well as
other recent immunizations (HPV, Hepatitis B, pneumococcal disease, influenza)
Ask what other medical practitioners the patient sees and whether he or she wants
copies of your report sent to them. Patients have the right not o have information
sent to other doctors if they choose.

Additional History for the Female Patient

A menstrual history should be obtained, relevant for a woman with abdominal pain,
suspected endocrine disease or genitourinary symptoms.