HISTORY TAKING INTERNAL MEDICINE STUDENT.pdf
- 1. HISTORY TAKING IN INTERNAL MEDICINE (4TH YEAR, 2022/2023 ) DR. EDRIES A. TEJAN MB.ChB, PGDFM, FWACP, FRSTMH, FCPS CONSULTANT PHYSICIAN,GASTROENTEROLOGIST, HEPATOLOGIST DIGESTIVE ENDOSCOPIST
- 2. OUTLINE • • • • LEARNING OJECTIVES INTRODUCTION TO HISTORY TAKING SETTING THE SCENCE FOR HISTORY TAKING STEPS FOR HISTORY TAKING
- 3. LEARNING OBJECTIVES • At the end of this lecture the students must be able to Why is history taking important in the art of medicine Difference between symptoms and signs Elucidate the different components of history taking The symptoms characteristic of the different systems Writing a summary of a history
- 4. INTRODUCTION (1) • • In order to achieve the aim of relieving the suffering of every patient, it is most essential to understand what has gone wrong with normal human physiology in that individual, and how the patient’s personality, beliefs and environment are interacting with the disease process History taking and clinical examination are crucial initial steps to achieving this understanding, even in an era in which the availability of sophisticated investigations might suggest to a lay person that a blood test or scan will give all the answers
- 5. INTRODUCTION (2) • • The aims of any first consultation are to understand patients’ own perceptions of their problems and to start or complete the process of diagnosis. This double aim requires a knowledge of disease and its patterns of presentation, together with an ability to interpret a patient’s symptoms (what the patient reports/complains of, e.g. cough or headache) and the findings on observation or physical examination (called physical signs or, often, simply ‘signs’).
- 6. INTRODUCTION (3) • • • Symptoms are what the patient complains of Signs are what the doctor elicits on examination Appropriate skills are needed to elicit the symptoms from the patient’s description and conversation, and the signs by observation and by physical examination.
- 7. INTRODUCTION (4) • • • There are two main steps to making a diagnosis: 1 To establish the clinical features by history and examination – this represents the clinical database. 2 To interpret the clinical database in terms of disordered function and potential causative pathologies, whether physical, mental, social or a combination of these.
- 8. SETTING THE SCENE FOR HISTORY TAKING • • • • • • The location for history taking may be the wards, consultation rooms and even during final exams The location should be conducive for both the patient and the medical student. Usually there should be no 3rd party for an adult except when the patient has consented to do so Introduction of the doctor or medical student to the patient is paramount Interviewer should be polite and speak the language that the patient can converse comfortably in. Interpreters may be used. Try to ask open ended questions
- 9. FACETS/STEPS OF HISTORY TAKING 1. 2. 3. 4. 5. 6. 7. 8. 9. Demographic data Presenting Complaints (PC) / Chief complaints History of presenting complaints (HPC) Systemic Review Past Medical history (PMHx) Social history (SHx) Family history (FHx) Drug and Allery Hx (DAHx) Summary of the history
- 10. Demographic data • • • • • • • Name of patient Age Sex Address Tribe Marital status Occupation
- 11. Presenting Complaints/Chief Complaints (1) • • • This should be recorded in the patient’s own words It is very important to use vocabulary that the patient will understand and use appropriately. This understanding needs to be on two levels: he must understand the basic words used, and his interpretation of those words must be understood and clarified by the doctor You should get a clear understanding of what the patient meant and not just take them for what they report.
- 13. Presenting Complaints/Chief Complaints (3) • • • • • • • The presenting complaints are the main symptoms reported by the patient There are usually 2 or 3 symptoms, they should not be more that 4 symptoms Symptoms are given in a chronological manner Eg. Breathlessness for 2 weeks Swelling of the feet for 1 week Palpitations for 3 days
- 14. Presenting Complaints/Chief Complaints (4) • • • Breathlessness x 2/52 Swelling of the feet x 1/52 Palpitations x 3/7
- 15. History of Presenting Complaints (1) • • Each symptom should be described completely before moving to the next symptom Important clues about the history of a symptom include Mode and time of onset How it has developed and varied Aggravating and relieving factors Eg when did the breathlessness start, how did it start, how has it progress, has it gotten worse over time, what makes it worse, what makes it better
- 16. Presenting Complaints/Chief Complaints (2) • • • • • • • • • Pain is one symptom that you can ask direct questions eg: SOCRATES Site Onset: sudden/gradual Character: sharp/dull/aching/squeezing/burning/colicky/crushing/ tearing/stabbing Radiation Alleviating or relieving factors. Associated symptoms Timing: constant/episodic Exacerbating factors Severity: mild/ moderate/ severe
- 17. Systemic Review (1) • • • During this phase of the history, the student should ask about the presence of all symptoms in all the systems It is customary to have asked the other symptoms in the system where the presenting complaints fall. General: fever, weight loss ,generalised body pains, fatigue.
- 18. Systemic Review (2) • • Cardiovascular system: dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, exercise intolerance, chest pain, palpitation, ankle edema, intermittent claudication Respiratory system: cough, sputum, hemoptysis, dyspnea, stridor, sore throats, wheeze, pleuritic pain, weight loss/night sweats/fever, TB contacts.
- 19. Systemic Review (3) • • Gastrointestinal system: Appetite, chest burns, dysphagia, odynophagia, yellowness of the sclera, regurgitation, nausea, vomiting, hematemesis, abdominal pain, abdominal swelling, constipation, diarrhea, nature of stools, melena, hematochezia. Central Nervous system: headaches, dizziness, faints, seizure/convulsion, tinnitus, vertigo, speech, hearing, vision, sleep habits, weakness, incoordination, sensory loss, gait.
- 20. Systemic Review (4) • • Genitourinary system: suprapubic pain, loin pain, urine odour, dysuria, hematuria, frequency, nocturia, hesitancy, urgency, urge incontinence terminal dribbling, urethral discharge In women: vaginal discharge, dysmenorrhea, post coital bleeding, LNMP, post menopausal bleeding etc.
- 21. Systemic Review (5) • • • Endocrine system: polyuria, polydipsia, goiter, skin pigmentation, exophthalmos, heat intolerance Locomotor: joint pain, joint swelling, joint stiffness, joint deformity, muscle weakness, muscle pain, muscle stiffness, bone pains Skin: rash/scar/sore/swelling/itch, hair loss, skin allergy, pigmentation
- 22. Past Medical History • • • • • Ask for chronic illnesses: Hypertension, Diabetes, Asthma, COPD, Epilepsy, Sickle Cell Disease Any previous hospital admission Any previous surgery done Any previous road traffic accidents. Any previous blood transfusion
- 23. Social History (1) • • • Occupation Type of work done Any exposure at work: In some situations, a patient’s occupation will be directly relevant to the diagnostic process. The classic industrial illnesses, such as lead poisoning and other toxic exposures, are now extremely rare in developed industrial countries, but accidental exposure continues to occur
- 24. Social History (2) • • • • • Smoking: type, if cigarettes then no of sticks per day and duration smoked. Alcohol: No of pints per day, duration. Calculate the gram of alcohol taken per day Travels Parties Multiple sexual partners
- 25. Family History
- 26. Drug and Allergy history • • • • • • Is the patient taking any prescribed drug for any chronic medical illness Is the patient on any drug(prescribed or self medicated) for the present illness Is the patient taking any over the counter medications What about inhalers, skin patches or cream, suppositories or tablets to suck Any use of herbal medications. Any allergy to drugs or food? Brief explanation of the allergic reaction
- 27. Summary • • • At the end of taking the history, the student must be able to summarise the history in 2 or 3 sentences This summary should contain key demographic data, presenting complaints, important associated symptoms, key negative symptoms and important past medical history Also the students must be able to construct a differential diagnosis
- 28. THANK YOU