Holistic History Taking & Hands-on Diagnostics

Question 1

3 main stages in history taking

Answer 1

• Introduction: to establish effective rapport
• The principal stage: listen carefully to the
patient
• Questioning stage: to clarify the history and to obtain information about the present symptoms, previous health, family history, social setting etc

Question 2

The important aspects of the history

Answer 2

Patient details and details of informant (if relevant)
Presenting complaint (PC)
History of present complaint (details of the current illness) (HPC)
Past medical history (PMH)
Drug history & Treatment history (DH, Rx)
Allergies
Family history (FH)
Social history & Personal History (SH)
Systemic enquiry (SE, RoS)

Question 3

Presenting complaint

Answer 3

• The main reason for the patient seeking medical advice
• Usually a single symptom, but occasionally several e.g.: chest pain, palpitation, shortness of breath and ankle swelling
• Include:
• Timing – fever for last two weeks or since Monday, Intermittent episodes of abdominal pain/cough for one month
• Any known major disease which may be relevant e.g. DM, asthma, hypertension, pregnancy, IHD

Question 4

History of presenting complaint -

Tips

Answer 4

Full details of the presenting complaint(s)

e. g. time of onset, evolution, aggravating or relieving factors, any pattern to symptoms, associated positive or negative symptoms, any investigations or treatment & outcome
- Have a differential diagnosis in mind
- Lead the conversation and thoughts to help determine the differential diagnosis and ultimately the diagnosis
- If several complaints try and determine which if at all possible are the most important

Question 5

Analysis of symptoms 1

With all symptoms need to know:

Answer 5

• Duration
• Onset : sudden or gradual
• What has happened since: constant or
  intermittent , frequency , getting worse or
  better
• Precipitating or relieving factors
• Associated symptoms

Question 6

Analysis of symptoms 2

eg: “Pain” – what are the features you need to know about?

Answer 6

main site- frequency and periodicity
radiation- special times of occurrence
character -aggravating factors
severity -relieving factors
Onset / duration -associated phenomena

Question 7

Past medical history

Answer 7

Start by asking:
-Existing medical problems
IHD/ Heart Attack/ DM/ Asthma/ HT/ RHD,TB/ Jaundice/ Seizures
e.g. if diabetic - mention time of diagnosis/current medication/clinic
follow up arrangements
-Past surgical/operation history
e.g. What type of operation, why, when and where. Note any blood transfusion and blood grouping
-History of trauma/accidents
e.g. What type of accident, when and where
-History of foreign travel

Question 8

Drug History

Answer 8

Drug History (DH)
Always use generic name or put trade name in brackets with dosage, timing and how long
e.g. Ranitidine 150 mg PO BD
Note: do not forget to ask about OTC / Vitamins / Traditional medicines and illicit drug use
Allergies to drugs

Question 9

Family History

Answer 9

Any familial disease e.g. asthma and other atopic conditions, IHD, DM, psychiatric illness, breast cancer, other cancers, developmental delay
Parents, siblings, partner, own children, wider family

Question 10

Other relevant history if not already obtained

Answer 10

Obstetric/Gynae history if females
In children - pregnancy and birth history, feeding history, developmental history, school, immunisation history
Note: Ask for the child health record / red book
Travel and sexual history if suspected STI or infectious disease

Question 11

Systemic or systems review (SR)

Answer 11

Gastrointestinal
• Weight: Weight loss, appetite change
• Working down the body:
– Dysphagia
– Nausea/vomiting
– Indigestion/heartburn
– Abdominal pain
– Bowel habit change
– Blood/mucus in stool

Question 12

Basic Clinical Skills

Answer 12

• CLEAN
– Make sure your hands are clean
– Gel before touching a patient (for their protection)
– Gel after touching a patient (for your protection)
– Use GLOVES if near bodily fluids
• CONSENT
– Always get permission before touching a patient or a fellow student.

Question 13

Basic Schemes

Answer 13

Inspection
Palpation
Percussion
Auscultation
• Site
• Onset
• Character
• Radiation
• Associated features
• Timing
• Exacerbation
• Severity
• (Cause)
See
Touch
Taste ??
Smell
Hear

Question 14

Abdominal Examination

Answer 14

• Introduction
– Wash hands
– Introduce yourself
– Confirm patient details
– Explain examination and obtain consent
– Expose patient and lie patient flat

Question 15

Abdominal Examination –

Inspection

Answer 15

• General Inspection
– Patient: stable, pain/discomfort, jaundice, pallor, muscle wasting/cachexia,
– Around bed: vomit bowels, stoma bags, drains, etc
• Hands, Head & Neck – beyond the scope of today’s session.

Question 16

Abdominal Examination - Palpation

Answer 16

• Ask the patient if they have any pain (examine these areas last)
• Light Palpation (examine all 9 quadrants):
• Observe the patient for:
– Tenderness
– Rebound tenderness
– Guarding
– Masses

• Deep Palpation (examine all 9 quadrants) to detect masses – assess:
– Location
– Size
– Shape
– Mobility
– Consistency
– Pulsatility

• Palpate the liver - beyond the scope of today’s session.
• Palpate the spleen - beyond the scope of
today’s session.
• Palpate the kidneys - beyond the scope of today’s session.
• Palpate the aorta - beyond the scope of
today’s session.

Question 17

Abdominal Examination -

Percussion

Answer 17

• Percussion of the abdomen is usually resonant due to bowel gas.
• Over a distended organ it will be dull
indicating organomegaly (abnormal
enlargement of organs)
• Liver
• Spleen
• Bladder
• Ascites – percuss for shifting dullness

Question 18

Abdominal Examination -

Auscultation

Answer 18

• Bowel sounds
– Listen just above the umbilicus. You should be listening for gurgling (normal).
– Absence of bowel sounds (after listening for two minutes) implies ileus, tinkling implies bowel obstruction.
• Bruits - beyond the scope of today’s session

Question 19

Summary

Answer 19

• Check for ankle oedema
• Thank the patient and cover them
• Summarise examination findings