Download An Introduction for History Taking and Clinical Examination

Dr. Abdelmonem Gado, MS Surgery, FRCSI
Consultant Paediatric Surgeon, Division of
Paediatric Surgery, Department of Surgery
•Your
professional obligations, the
expectation placed upon you by the
public, the law and your colleagues,
start on your first day as a student
and continue throughout your
working life.
The qualities that patients look for in a
doctor:
•
•Humaneness
•Competence
•Accuracy
•Honesty
•Openness
•Responsiveness
•Trusthworthiness
•Involving the patient in the decision making
process
•Time and listen
-Language:
- Learn to speed read
- A good clinician is someone who interested in
people
-Put yourself in situation of the patient or their
relatives
-The best doctor are invariably the most humble and
-good observer
-Dress, Demeanour and confidentiality to establish
successful patient – doctor relationship
Set-up:
-Where will you see your patient?
-Keep always quite and private space
-How long this interview?
-How will you sit?
Hand washing and Cleanliness:
- Is the single most effective way to
prevent the spread of infection
Infections that can be transmitted on the
hands of healthcare workers”
-Healthcare – acquired infections:
-MRSA - Clostridium difficile
-Diarrheal infection:
- Salmonella - Shigella - E.coli - Noro virus
- Respiratory Infection:
- Influenza
- Common cold
virus (RSV)
- Other Infections:
Hepatitis A
- Resp. Syncytial
Communication Skills, How?
-Maintain good eye contact
-Active listening, then write
-Encourage verbal or non verbal
communication
-Avoiding jargon
-Ability to discuss difficult issues
-Going at a place that is comfortable for
the patient
-Diligent and frequent practice
Introduce yourself:
-I am Mr…., I am 3rd year medical
student
-I have been asked to talk to you and
examine you with some of my
colleagues
-It might take 30 minutes
-Privacy
-Notes (it does not mean I’m not
listening to you
-Are you happy with all that?
Things to remember:
-Never write while talking
-See the patient walking
-See the accompanying person (mother,
wife, friend)
-Can often provide valuable information
-However, many patients are inhibited from
discussing their problems by the presence of
third person
Guide the conversation:
-Explain what you are doing, and why you
are doing it, at all stages
- patients know more about their
complaints than you, but cannot interpret
their significance:
- Interpreter – short and simple
questions
- Leading questions
- one answer
- open questions
- Example : Does the pain ever move?
- Always ask the questions in the right
way.
Principle of History taking in Surgery:
History taking
? the key step in surgical diagnosis.
Varies according to the complain
? specific histories
? surgical specialty
Out-pt or emergency room history
?specific complaint is pinpointed ? diagnosis
Clerking of pt admitted for elective surgery object
? to assess that the treatment planned correctly indicated
and pt is suitable for that operation.
Information gathered during patient
interview
•
- Date and Time
- Chief Complaint
- Identifying data
- Present illness
- Source of referral
- Past medical and
surgical history
-
Source of history
- Family History
Social History
- Drug History
-
I.
Personal Information
- Age, Sex, marital status, occupation
nationality, residence, etc..
HISTORY cont..:
2) Present complain:
- open question
- closed question
- write in patients words

•
•
Symptoms that caused patient to seek care
Often:
• Pain
• Abnormal function
• Change in normal state
• Unusual observation made by patient (e.g., heart
palpitations)
3) History of present illness
(Complaint)
- Provide full, clear, chronological
account of symptoms
- In scientific term
- Similar attacks
- Determine the abnormal system
HISTORY cont..:
4)
Remaining question of abnormal system
HISTORY cont.:
Systemic direct question:
5)
◦
◦
it reveals the presence of other disorders of
which the patient was unaware, or thought
irrelevant
-ve answers are as important as +ve answers
•
•
•
•
•
•
•
Appetite
Diet
Weight
Teeth and Taste
Swallowing
Regurgitation
Flatulence
-
Heartburn
Vomiting
Haematemesis
Indigestion
Abdominal pain
Defecation
Change of skin
Color
-Cough
-
Sputum
Haemoptysis
Dyspnea
Orthopnea
Chest pain
-
-
Breathlessness
Orthopnea
Paroxy swal noctural dyspnea
Pain
Palpitations
Cough and sputum
Dizziness and headaches
Ankle swelling
-
-
Pain
Oedema
Thirst
Micturation
Urine –haematuria
-
Scrotum & urethra
Menstruation
Dyspareunia
Breast
Secondary sex
character

Nervous system and
musculoskeletal system

General state of health:
◦
◦
◦
◦
Childhood illnesses
Adult illnesses
Accident and injuries
Surgeries or hospitalizations

Health of immediate family
◦ High blood pressure, heart disease, contagious
illnesses

Potential for hereditary diseases

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Marital status
Occupation
Residency
The lesiure activities
Habits (smoking, alcohol,etc)
Travelled abroad.

Alcohol or drug use

Physical abuse or violence

Sexual issues

Respect patient privacy

Be direct and firm

Avoid confrontation

Be nonjudgmental

Use appropriate language

Document carefully
◦ Use patient’s words when possible

Silence

Overly talkative patients

Patients with multiple symptoms

Anxious patients
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Anger and hostility
Intoxication
Crying
Depression
Sexually attractive or seductive patients
Confusing behavior or histories
Limited intelligence
Developmental disabilities

May result from:
◦ Social or cultural differences
◦ Sight, speech, or hearing impairments

Attempt to find assistance to aid in
communication


Pain
Lump

History of pain
-The site
-Onset
-Duration
-Severity
-Nature of the pain
-Progression of the pain
-Relieving and exacerbation factors
-Radiation and refering pain

History of a lump
-Site.
-Duration.
-What made the patient notice the lump.
-course of the lump.
-Associated symptoms.
-Other lumps
 QUIZ
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QUESTIONS?
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THANK YOU!