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BY
Georges Metellus, M.D., M.P.H
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The history is the single most important tool in
obtaining a diagnosis. It is an extraordinary
investigative technique.
History taking requires a clinician-patient inter
action and therefore, a connection between the
two is important for the objectivity of the
process. Your attitude of friendliness and
obvious respect will go a long way in the
pursuit of information and ensuring your
patient’s help in obtaining.
Patient-Doctor connection: This can be achieved through:
A. Active listening:
1. Choose a mutually comfortable setting (including taking
into consideration the patient’s circumstances)
2. Remain quiet and attentive
3. Avoid interrupting unless you really have to.
4. Do not anticipate the next question before you have heard
the complete answer.
5. A good history requires that the doctor be aware of and
be sensitive to cultural differences.
6. Strive to remove your own beliefs, prejudices, and
preconceptions from observations.
7. Communication: verbal an non-verbal (body language)
8. Avoid sophisticated medical jargon.
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Patient-Doctor Connection (cont”)
B. Accuracy and reliability of information:
1. Information obtained must be sufficiently detailed and
unambiguous to use in diagnosis and treatment.
2. Avoid leading Questions
3. In case of doubt, clarify by asking questions such as “what do
you mean?”
4. Be reassuring: involves making an educated guess regarding
what the patient is likely to be worried about and dealing
specifically with those worries.
5. Be careful when dealing with moments of tension generated by
anxiety feeling, depression, crying, dementia…
7. Be aware of manipulation, seduction, anger, alcoholism, sexual
uncertainties.
The structure Include:
1. Identifying Information: date, time, age, sex race,
occupation, and referral source.
2. Chief complaint (CC): is a brief statement of the reason
the patient is seeking health care. Directly quoting the
patient is helpful. It may include the duration of the
problem.
3. History of Present Illness (HPI): is a thorough
elaboration of the chief complaint and other current
symptoms starting from the time the patient last felt
well until the present. State of health just before the
onset of the present problem. Exacerbation and
relieving factors. History of exposure to infection or
toxic agents. Medication. Stability of the problem.
Impact on the patient’s usual life style.
4. Past Medical History (PMH):
 Childhood illness: Measles, mumps, whooping
cough, chicken pox, smallpox. Scarlet fever…
 Major adult illnesses
 Immunizations
 Surgery
 Serious injuries
 Medications
 Allergies
 Transfusion
 Hospitalization
 Emotional status
5. Family History (FM):
 Ask if there are any blood relatives in the patient’s
family who have illnesses with features similar to the
patient’s illness.
 Determine the ethnicity; health; and, if applicable, the
cause of death of parents and siblings, including their
age of death
 Establish whether there is a history of heart disease,
high blood pressure, cancer, TB, stroke, epilepsy,
diabetes, gout, kidney disease, thyroid disease, asthma
and other allergic states, forms of arthritis,blood
disease, STDs…
 Determine the age and health of the spouse’s parents
and children
7. Personal and Social History (SH)
 Personal status: Birth Place, home environment,
socioeconomic class, cultural background,
education, marital status, general life satisfaction,
source of stress…
 Habit: Nutrition and diet; regularity and patterns
of eating and sleep; exercise; ; coffee, tea, tobacco ,
alcohol, use of recreational drugs (frequency,
type). Breast or testicular self-examination, sexual
history, home conditions, occupation,
environment, military record, cultural
requirement…
Review of System (ROS)
 A few questions about each major body system
ensures that problems will not be overlooked.
 The physician should avoid the mechanical
“rapid fire” questioning technique that
discourage patients from answering truthfully
because of fear of ‘annoying the doctor”
The Physical examination begins as one is
taking the history, by observing the patient and
beginning to consider a differential diagnosis.
1.General appearance:
 Patient’s body habitus
 State of grooming
 Nutritional status
 Level of anxiety
 Degree of pain or comfort, mental status,
 speech pattern and use of language
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Are considered the baseline indicators of a
patient’s health status. They may be measured
early in the physical examination.
Pulse
Respiration
Blood Pressure
Temperature
Measurement of height and weight
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The pulse may provide information about the
rate, strength, and rhythm of the heartbeat.
The pulse may be palpated in several different
areas. The nine major “pulse points” are named
after the arteries over which they are felt.
To feel a pulse, you must place the pads of
your second and third fingers over an artery
that lies near the surface of the body and over a
bone or a firm base.
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1. Over the superficial temporal artery in front of the ear.
2. The common carotid artery in the neck along the front
edge of the sternocleidomastoid muscle.
3. Over the facial artery at the lower margin of the mandible
at a point below the corner of the mouth.
4. In the axilla over the axillary artery
5. Over the brachial artery at the bend of the elbow along the
inner or medial margin of the biceps brachial muscle
6. At the radial artery at the wrist (radial pulse). It is the
most frequently monitored and easily accessible in the body
7. Over the femoral artery in the groin.
8. At the popliteal artery behind and just proximal to the
knee
9. At the dorsalis pedis artery on the front surface of the
foot, just below the bend of the ankle joint
TYPE/DESCRIPTION
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Pulsus alternans: regular
rate; amplitude varies from
beat to beat alternating weak
and strong beats
Bigeminal pulse: Two beats
in rapid succession (one
normal, one premature)
followed by longer interval;
easily confused with
alternating pulse.
Pulsus bisferiens: Two
strong systolic peaks
separated by a midsystolic
dip.
ASSOCIATED
CONDITIONS
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Left ventricular failure
Regularly occurring
ventricular premature
beats
Aortic regurgitation
alone or with stenosis
TYPE/DESCRIPTION
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Bounding pulse:
increase pulse pressure;
contour may have rapid
rise, brief peak, rapid
fall (hyperkinetic pulse).
Bradycardia: rate <60
ASSOCIATED
CONDITION
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Artherosclerosis, aortic
rigidity, patent ductus
arteriosus, fever, anemia,
hyperthyroidism, anxiety,
exercise
Hypothermia,
Hypothyroidism, drug
intoxication, impaired
cardiac conduction,
exellent physical
conditioning
TYPE/DESCRIPTION
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Paradoxic pulse:
Amplitude decreases
(>10mmHg)on inspiration
and increases on
expiration
Pulsus differens: Unequal
pulses between left and
right extremities
Tachycardia: Rate over
100
ASSOCIATED
CONDITIONS
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Chronic obstructive
disease, constrictive
pericarditis, pericardial
effusion
Impaired circulation,
usually from unilateral
local obstruction
Fever, hyperthydoidism,
anemia, shock, Heart
disease, anxiety, exercise
TYPE/DESCRIPTION
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Trigeminal pulse: three beats
followed by a pause.
Water-hammer pulse (Corrigan
pulse): Jerky pulse with full
expansion followed by sudden
collapse
ASSOCIATED
CONDITIONS
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Often benign, such as
after exercise; but may
occur with
cardiomyopathy, severe
ventricular
hypertrophy, severe
aortic stenosis,
dysfunctional right
ventricle.
Aortic regurgitation
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Blood pressure is the pressure or “push” of
blood as it flows through the circulatory
system. It is a peripheral measurement of
cardiovascular function.
Indirect measures of blood pressure are made
with a stethoscope and a sphygmomanometer
(aneroid or mercury) or with electronic
sphygmomanometers which do not require the
use of a stethoscope
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Blood Volume
The strength of each heart contraction
Heart rate
The thickness of blood (viscosity)
Rigidity of the arteries
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The larger the volume of blood in the arteries,
the more pressure the blood exerts on the walls
of the arteries.
The less blood in the arteries, the lower the
blood pressure tends to be. (Hemorrhage
demonstrates this relation between blood
volume and blood pressure)
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A stronger heartbeat increases blood pressure
and a weaker beat decreases it.
Cardiac output is also influenced by the
strength of the contraction of the heart
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The rate of the heart also affects arterial Blood
pressure. When the heart beats faster, more
blood enters the aorta, therefore the arterial
blood volume and blood pressure would
increase.
The stroke volume is to be considered because
it might determine whether or not the blood
pressure is going to change in one way or
another
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If blood becomes less viscous than normal,
blood pressure decreases. (if a person suffers a
hemorrhage, fluid moves into the blood from
the interstitial fluid. This dilutes the blood and
decreases its viscosity, and blood pressure)
In a condition called Polycythemia, the number
of red blood cells increases beyond normal and
thus increases blood viscosity. This in turn
increases blood pressure.
Increased arteriolar resistance is the most
common cause of hypertension. This increase
may occur secondarily to:
1. Endocrine causes:
Tumor of the adrenal medulla (
Pheochromocytomas) produces epinephrine
and norepinerphrine and may give rise to
paroxysmal form of hypertension
2. Renal Causes:
2. Renal Causes
a) Renal parenchyma:
Chronic glomerulonephritis
Pielonenephritis
Polycystic disease
b) Renal vasculature
vascular lesions due to congenital or acquired malformation of
the renal artery or to small vessels disease as such in lupus
erythematosus.
3. Essential Hypertension: is the most common cause of a
pathologically elevated blood pressure. The disease shows a marked
familial tendency, and it appears commonly in middle-aged people. It is
one of the most common causes of left ventricular Hypertrophy.
Hypotension results from:
1. Decrease of cardiac output:
In Addison’s disease, myocarditis, myocardial infarction,
pericarditis with effusion, and following hemorrhage
2. Decrease in peripheral resistance
Vasomotor collapse, may occur in:
Pneumonia
Septicemia
Acute Adrenal insufficiency (Waterhouse-Frederichsen syndrome)
Drug intoxication
( a sudden drop in blood pressure should be regarded as a grave sign)
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Respiration means exchange of gases( oxygen and
carbon dioxide) between a living organism and its
environment
Respirations are counted and evaluated by
inspection. Observe the rise and the fall of the
patient’s chest and the ease with which breathing
is accomplished. Count the number of respiratory
cycles (inspiration and expiration) per minute.
Observe the regularity and rhythm of the
breathing pattern.
Note the depth of respirations and whether the
patient uses accessory muscles.
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Tachypnea: Is a persistent respiratory rate
approaching 25 respirations per minute.
Certain patients with fibrosis of the lung,
pulmonary edema, pleural disease, or rib cage
fixation may breathe rapidly and shallowly.
Other patients may increase the minute
ventilation to accommodate an increased gas
exchange that is necessitated by exercise, fever,
hypermetabolic states, or anxiety
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Bradypnea: rate slower than 12 respiration per minute.
May indicate neurologic ( i.e intracraneal pressure:
hemorrhage, tumor) or electrolyte disturbance,
infection or a sensible response to protect against the
pain of pleurisy or other irritative phenomena (it may
also mean splendid level of cardiorespiratory fitness)
Kussmaul Respiration: deep, rapid and labored
respiration associated with metabolic acidosis. May
indicate decompensated diabetes with profund
acidosis; renal diseases or drug causing acidosis.
Diseases of the central nervous system, such as
meningitis, may increase minute ventilation
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Cheyne-Stokes respiration: A regular periodic pattern
of breathing, with intervals of apnea followed by a
crescendo/decrescendo sequence of respiration. It
occurs in patients who are seriously ill, particularly
those with brain damage at the cerebral level or with
drug-caused respiratory compromise.
Biot Respiration: Consists of somewhat irregular
respirations varying in depth and interrupted by
intervals of apnea. It is usually associated with severe
and persistent increase intracranial pressure,
respiratory compromise resulting from drug
poisoning, or brain damage at the level of the medulla.
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The assessment of body temperature may often
provide an important clue to the severity of a patient’s
illness. Temperature measurement can be
accomplished through several different routes, most
commonly:
oral,
rectal,
axillary,
tympanic membrane (less common)
In the case of bacterial infection it may well be the most
critical diagnostic indicator, especially with infants,
toddlers, and the elderly
Important conditions related to body temperature:
1. Fever: Is an unsually high body temperature associated
with a systemic inflamatory response. In the case of
infections, chemical called Pyrogens cause the thermostatic
control centers of the hypothalamus to produce fever.
2. Malignant hyperthermia: Is an inherited condition
characterized by an abnormally increased body temperature
and muscle rigidity when exposed to certain anesthestics
4. Heat exhaustion: Occurs when the body loses a large
amount of fluid resulting from heat-loss mechanism. This
usually happens when environmental temperatures are
high. The loss of water and electrolytes can cause weakness,
vertigo, nausea, heat cramps and possibly loss of
consciousness
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Heatstroke or sunstroke: is a severe condition
resulting from the inability of the body to
maintain a normal temperature in an extremely
warm environment. Such thermoregulatory
failure may result from factors such as old age,
disease, drugs that impair thermoregulation, or
simply overwhelming elevated environmental
temperatures.
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Hypothermia: is the inability to maintain a
normal body temperature in extremely cold
environments. Hypothermia is characterized
by body temperature lower than 35C (95F),
shallow and slow respirations, and a faint, slow
pulse.
Frostbite: is local damage to tissues caused by
extremely low temperatures. Necrosis and even
gangrene can result from frostbite.
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Procedures for accurately measuring height,
weight, and triceps skinfold. These measures are
useful in assessing a patient ‘s nutritional status
and possible disease risk.
Body Mass Index: is a formula used to assess
nutritional status and total body fat. It is a measure
of Kg per meter squared. For adult men and
women, a BMI between 18.5 and 24.9 is expected
Mid-Upper Arm Circumference: provides a rough
estimate of muscle mass and available fat and
protein store.
Obesity:
 Exogenous Obesity: there is an increase in the
number of fat cells, as much as 3 to 5 times normal
(excess fat tissue is generally located in the breasts,
buttocks, and thighs and is associated with
excessive calorie intake.
 Endogenous obesity: The fat cells are greatly
enlarged. Excess fat tissue is distributed to certain
regions of the body, such as the trunk, or
abdomonal area. Men are more likely to have this
type of obesity and is associated with higher risk
of diabetes, heart disease, high blood pressure, and
stroke.
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Anorexia Nervosa
Emotional disorder occurring most commonly in adolescent females,
characterized by abnormal body image, fear of obesity, and prolonged
refusal to eat, leading to emaciation, amenorrhea, and other symptoms,
and sometimes resulting in death.
Bulimia:
Potentially serious disorder, especially common in adolescents and young
women, marked by insatiable craving for food and leading to episodes of
excessive overeating, often followed by self induced vomiting, purging,
or fasting
Anemia
Condition in which the hemoglobin content of the blood is below normal
limits.
Hyperlipidemia:
Disorders resulting in higher than normal level of lipids in the blood
And
GOOD LUCK!