Introduction And Taking History

Question 1

What are the principles of patient assessment

Answer 1

• use a systematic approach
• practice infection control techniques
• establish a rapport
• ensure patients comfort as much as possible
• listen to what the patient says

Question 2

After establishing rapport by introducing yourself what do you have to do?

Answer 2

Initiate the session by asking questions

Question 3

Types of questions to ask

Answer 3

Open ended questions: questions that don’t limit the patient’s answers .Example: what is your name? , is there anything else?
Closed questions: giving the patients limited options
ExMples: what is your name. A. Bertha b. Patricia
Leading questions : isnt your name Patricia?

Start with open questions and after patient has talked a lot, ask closed questions to get your specific answers if the patient did not state something

Question 4

After taking history what do you do

Answer 4

Seek consent and start the physical examination to answer questions that are bothering you from the history
Example: if patient tells you he or she had yellow eyes, in your physical examination you’ll check if it’s true or what can cause it

Question 5

What is entire process

Answer 5

Initiate the session 
Gather information 
Physical examination 
Explanation and planning - explain to patient why they’ll need to do certain tests . How you’re gonna help the patient w the disease you found out
Close the session

Question 6

Session structure

Answer 6

Demographics
•Presenting  complaint
•History of presenting complaint
•Direct questioning
•systems review
•Past medical History/ past surgical history
•Family History
•Drug history
•social history

Question 7

Name some things to find out in demographics

Answer 7

Name
Age sex
Address
Occupation
MRital status 
Religion
Insurance status

Question 8

Explain presenting complaints

Answer 8

Complaints
•the main reason the patient came to see you
•may be single or multiple
•it should be recorded in the patients own words
•what brings you here today?
•in order of occurrence

Every presenting complaint must be recorded with a duration and written in order of occurrence depending on which symptom started first
Example- pain for two days or three hours along with its frequency

Question 9

Explain history of presenting complaints

Answer 9

•elaborate chief complaint
•ask relevant associated symptoms
•have differential diagnoses in mind
•lead the conversation
•formulate a story
•sequential presentation
•details of symptomatic presentation
It is the story behind the presenting complaint. It shows what happened

Question 10

ODQs are what kind of questions

Answer 10

Close questions

Question 11

You can only tap the patients shoulder to comfort the person true or false

Answer 11

True

Question 12

Make sure you confirm the information you got from the patient is true before you let the patient leave

Answer 12

Example: patient said pain started after two years
But you wrote one year
So you need to say Please so you said this and this and this then you confirm if you got the truth

Question 13

How to record pain

Answer 13

SOCRaTEs
S- site 
O- onset(speed of onset
C- character( eg. sharp, dull,burning,stabbing)
R- radiation( of pain or discomfort . Does the pain go anywhere else)
A- alleviating factors
T- timing (when does pain get worse
E- exacerbating factors
S- severity(scale of 1-10

Relationship to any function- what patient does that the pain comes or pain gets worse

Question 14

Name four causes of melaena stools

Answer 14

Causes. The most common cause of melena is peptic ulcer disease. However, any bleeding within the upper gastrointestinal tract or the ascending colon can lead to melena. Melena may also be a complication of anticoagulant medications, such as warfarin.

Question 15

Hematemisis is

Answer 15

Vomiting blood

Question 16

How different is malaena from hematochezia

Answer 16

Hematochezia is the passage of fresh blood through the anus, usually in or with stools (contrast with melena). The term is from Greek αἷμα (“blood”) and χέζειν (“to defaecate”). Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper gastrointestinal bleed

Question 17

Define hemoptysis

Answer 17

Coughing up blood

Question 18

What do the BMI weight ranges mean

Answer 18

BMI below 18.5 is underweight. BMI of 18.5 to 24.9 is healthy weight. BMI of 25 to 29.9 is overweight. BMI of 30 and above is obese.

Question 19

Difference between dysphasia and odynophagia

Answer 19

Dysphagia- difficulty swallowing liquids or solids

Odynophagia- pain during swallowing

Question 20

Indigestion is also called

Answer 20

Dyspepsia

Question 21

Pneumatic and inhibitory sensors are associated w

Answer 21

Respiratory system

Question 22

Asterixis is also seen in respiratory failure due to carbon dioxide toxicity (hypercapnia) or retention
True or false

Answer 22

True

Question 23

What is myomectomy

Answer 23

Surgery to remove fibroid from the uterus

Question 24

What is xanthelasma

Answer 24

Lipid deposits in parts of the body especially under the eye

Question 25

With systemic enquiry,generally what are you supposed to ask(MAWSF)
Name five things that can cause weight gain and explain how they cause it
Name five things that can cause weight loss and explain how they cause it
What is cachexia

Answer 25

Ask about the weight(what the patient used to realize he or she has lost of gained weight for example their shorts were so loose on them,appetite, fever, sleep and mood.
(Mawsf)

Weight gain:1.hypothyroidism(When thyroid levels are low, your metabolism slows down and you burn less energy, even when you’re resting. You are also less likely to burn fat for energy, which can cause weight gain. An unexplained change in weight is one of the most common signs of a thyroid disorder. Usually weight loss is said to be for hyperthyroidism but sometimes it can cause weight gain cux it increases your appetite)
,2.poly cystic ovarian syndrome(Insulin resistance is the main cause of weight gain in women with polycystic ovary syndrome. Insulin resistance is when some cells in the body do not respond to the insulin produced by the pancreas. As a result, the pancreas produces more insulin to maintain normal blood sugar levels. This leads to more androgen production and weight gain. This creates a vicious cycle wherein the insulin resistance increases, so does the symptoms and the weight gain. ) 3.menopause-At menopause, many women experience weight gain, particularly around the abdomen. Contributors to weight gain at menopause include declining oestrogen levels, age-related loss of muscle tissue and lifestyle factors such as diet and lack of exercise.,4.depression,5.Cushing syndrome-(High levels of cortisol result in a redistribution of fat, especially to the chest and stomach, along with a rounding of the face.)

Weight loss: 1.cancer-Cancer cells demand more energy than healthy cells, so your body may burn more calories at rest than it normally would. The cells also release substances that affect how your body uses calories from food, which also can contribute to weight loss ,2.COPd-When your lungs don’t work as well as they should, your body has to work harder to breathe. This can cause you to burn up to 10 times more calories than usual.and you’re tired more so you have decreased appetite. There’s also cachexia or wasting syndrome where you lose weight and muscle wasting or muscle loss ,3. Crohn’s disease (Even with sufficient caloric intake, weight loss can happen because of the inflammatory process in Crohn’s disease. Inflammation can lead to increased consumption of the body’s stored energy and a breakdown of body tissues, both of which can lead to weight loss. An increased demand for protein is often the result of chronic inflammation. When this happens, your body may start to break down muscle and other fat-free areas of mass. The decrease in muscle mass can cause you to lose weight,4.diabetes-people with diabetes, insufficient insulin prevents the body from getting glucose from the blood into the body’s cells to use as energy. When this occurs, the body starts burning fat and muscle for energy, causing a reduction in overall body weight.
5.Parkinson’s- Gradual loss of the sense of smell and taste is a non-motor PD symptom that makes eating less enjoyable.Motor symptoms like tremor, slowness and stiffness and complications of treatment such as dyskinesia (involuntary extra movements) can make eating difficult.
* Swallowing difficulties are common in PD and can interfere with eating.and they can eat slowly cuz of this
People who experience depression or apathy — common non-motor PD symptoms — may lose their appetite 6.hypercalcemia

Question 26

What are you supposed to ask under respiratory system and cardiovascular system for SE(systemic enquiry)
What does pain in legs ofyen indicate

Answer 26

Ask about cough(character of the cough ,what makes the cough worse , sputum production(colour and amount),chest pains(when breathing in or when coughing?), haemoptysis(estimate of the amount of blood that came out),breathlessness or shortness of breath and wheeze.(5 things)

 Cardiovascular System
Ask about palpitations, breathlessness on lying flat (orthopnoea), chest pains (on exertion), ankle swelling, paroxysmal nocturnal dyspnoea(breathlessness at night) and tiredness. Breathlessness on minimal exertion.pain in legs on walking .Also ask about exercise tolerance for simple everyday things like climbing up a flight of stairs or walking uphill or even shaving in the mornings and leg pains on exertion.
(Seven things)

Do you ever have chest pain or tightness? Do you ever wake up during the night feeling
short of breath?
Have you ever noticed your heart racing or thumping?
Respiratory Are you ever short of breath?
Have you had a cough? If so, do you cough
anything up?
What colour is your phlegm? Have you ever coughed up blood?

Pain, commonly in the legs, caused by too little blood flow, usually during exercise. Often indicates peripheral artery disease.

Question 27

State ten things to ask under alimentary system and urinary system under SE(think of it like you’re doing abdominal exam and check what you’ll ask)

Answer 27

Ask about condition of the mouth or bleeding gums, nausea, vomiting, bowel habits and nature of the stools. Ask about abdominal pains, difficulty with swallowing(dysphagia) distinguish this from pain when swallowing which is odynophagia , belching, haematemesis, epigastric fullness and flatus. Ask about indigestion and weight loss, the colour of stools (pale, dark, tarry black or bloody stool)

Urinary System
Ask about dysuria, polyuria, nocturia, oliguria, stress and/or urge incontinence, if there’s blood in urine,poor stream and stress incontinence. Also ask about strangury which is a constant desire to urinate although there is little or no urine to be voided. Ask about the frequency of micturition both during the day and during the night.

Question 28

State six things each to ask under the CNs,locomotor system and the genital system under SE

Answer 28

 Nervous System
Ask about headache, numbness/tingling, muscle weakness, dizziness, vertigo, blackouts, fits, sleep pattern, vision and double vision, syncope, hearing (e.g. deafness, tinnitus) and disturbed sensation,fits,lightheadedness,altered sensation, Weakness
• Visual disturbance
• Hearing problems (deafness, tinnitus) • Memory and concentration changes
These symptoms need considerable amplification to make sure that the patient and the doctor mean the same thing.

Have you ever had any fits, faints or blackouts? Have you noticed any numbness, weakness or
clumsiness in your arms or legs?

Genital System
Ask about menarche, frequency and duration of periods, blood loss e.g. clots, flooding. Are periods painful? Ask about sexual activity, libido, impotence, infertility, urethral or vaginal discharge and post-menopausal bleeding.

Men
If appropriate: • Urethral discharge • Prostatic symptoms, including difficulty starting (hesitancy): • Erectile difficulties
• Poor stream or flow • Terminal dribbling

Women
• Last menstrual period (consider pregnancy) • Timing and regularity of periods
• Length of periods
• Abnormal bleeding
• Vaginal discharge
• Contraception
If appropriate:
• Pain during intercourse (dyspareunia)

Do you ever have pain or difficulty passing urine? Do you have to get up at night to pass urine? If so, how often?
Have you noticed any dribbling at the end of passing urine?
Have your periods been quite regular?

Musculoskeletal :Do you have any pain, stiffness or swelling in your joints?
Do you have any difficulty walking or dressing?

 Locomotor System
Ask about muscle pain or weakness, stiffness and swelling of the joints. • Joint pain, stiffness or swelling • Falls • Mobility

If from the history, any system is found to be the prime suspect, then one will need to expand on the sub-headings.
Also if mental illness is deemed to play a part then one will need to frame additional questions in this area.

Question 29

State five things that are asked during drug history and why

State five things asked during past medical and surgical history

Answer 29

Drug History
One must then ask the patient if he is taking any drugs, either prescribed by a doctor or acquired by the patient himself. Ask if they drink herbal medicine
Ask about allergies/hyper-sensitivities to drugs. Take the patient’s history of allergy seriously as patients have been known to die after they have been given a drug they are allergic to even though they told the doctor about their allergy but the doctor ignored the information. If the patient takes drugs,ask how long he’s taken the drugs,if he’s had any side effects since taking it ,what exactly he took the drugs for and the dosage, over-the-counter remedies, herbal and homeopathic remedies, and vitamin or mineral supplements. Do not forget to ask about inhalers and topical medications, as patients may assume that you are asking only about tablets. Note all drug names, dosage regimens and duration of treatment, adherence to therapy is likely (though not guaranteed) to improve.
Ask patients to describe how and when they take their medication. Give them permission to admit that they do not take all their medicines by saying, for example, ‘That must be difficult to remember.’
Drug allergies/reactions
Ask if your patient has ever had an allergic reaction to a medication or vaccine. Clarify exactly what patients mean by allergy, as intolerance (such as nausea) is much more common than true allergy.

Past Medical History
Now proceed to ask the patient about any past illnesses. Some patients would have forgotten and one has to jog their memory by asking if they have ever been admitted to hospital and with what condition. Has he had any surgery in the past? If so does he know what operation orhe had? Has he had any accident before? For which he or she was admitted?

Question 30

State nine diseases that should be asked when taking fam history and why
State nine things to ask when taking social history and why the person’s occupation is important
What questions do you ask about smoking?
What is a pack year
State how to calculate pack years
Quantity of alcohol is best estimated in units
How much is one unit of alcohol?
How much alcohol is too much for both males and females
Symptoms that improve over the weekend suggest what kind of disorder

Answer 30

Family History
Ask about a family history of tuberculosis, asthma,sickle cell disease,diabetes mellitus, systemic hypertension, gout, arthritis, epilepsy, mental illness and coronary heart disease like myocardial infarction. The presence of any of these illnesses in the family should increase one’s awareness of the possibility of the disease being present in the patient information about the age and health or the cause of death of the patient’s close relatives is often valuable.

Social History
Ask about the home conditions-establish the type and condition of the patient’s housing and how well it suits them, given their symptoms. Patients with severe arthritis may, for example, struggle with stairs. Successful management of the patient in the community requires these issues to be addressed., housing,facilities at home occupation(where the person works) interests, and habits. Ask about food, tobacco and alcohol consumption. Tactful exploration of income and commitments can follow, together with details of the educational background. One must then enquire in all cases about the occupational history, because some jobs can cause disease e.g. iron deficiency anaemia from hookworm infestation in farmers, Weil’s disease in sewage workers, mesothelioma in exposure to asbestors and dyestuffs and byssinosis in exposure in cotton dust.

Ask if your patient has ever smoked; if so, enquire what age they started at and whether they still smoke now. Patients often play down recent use, so it is usually more helpful to ask about their average number of cigarettes per day over the years, and what form of tobacco they have used (cigarettes, cigars, pipe, chewed). Convert to ‘pack-years’ (Box 2.7) to estimate the risk of tobacco-related health problems. Ask if they have smoked only tobacco or also cannabis. Never miss the opportunity during history taking to encourage smoking cessation, in a positive and non-judgemental way, as a route to improved health. Do not forget to ask non-smokers about their exposure to environmental tobacco smoke (passive smoking).
Alcohol
Alcohol causes extensive pathology, including not only hepatic cirrhosis, encephalopathy and peripheral neuropathy but also pancreatitis, cardiomyopathy, erectile dysfunction and injury through accidents. Always ask patients if they drink alcohol but try to avoid appearing critical, as this will lead them to underestimate their intake. If they do drink, ask them to describe how much and what type (beer, wine, spirits) they drink in an average week. The quantity of alcohol consumed each week is best estimated
in units; 1 unit (10 mL of ethanol) is contained in one small glass of wine, half a pint of beer or lager, or one standard measure (25 mL) of spirits.

2.7 Calculating pack-years of smoking
A ‘pack-year’ is smoking 20 cigarettes a day (1 pack) for 1 year
Number of cigarettes smoked per day × Number of years smoking divided by 20
For example, a smoker of 15 cigarettes a day who has smoked for 40 years would have smoked:
15 × 40 divided by 20 = 30 pack-years

The UK Department of Health now defines hazardous drinking as anything exceeding 14 units per week for both men and women.

Ask all patients about their occupation. Clarify what the person does at work, especially about any chemical or dust exposure. If the patient has worked with harmful materials (such asbestos or stone dust), a detailed employment record is needed, including employer name, timing and extent of exposure, and any workplace protection offered.
Symptoms that improve over the weekend or during holidays suggest an occupational disorder. In the home environment, hobbies may also be relevant: for example, psittacosis pneumonia or hypersensitivity pneumonitis in those who keep birds, or asthma in cat or rodent owners.

Question 31

What is the importance of traveling history or foreign travel history

What are the five important things to say in summary and give an example of summary of an history

Answer 31

Foreign Travel
History of foreign travel should be enquired. Certain tropical diseases e.g. amoebiasis and malaria is acquired by living in endemic areas. Hence any travel within and outside an area should be enquired about as it may give a clue to the present illness.
The importance of the history of travel is demonstrated by the fact that certain diseases are endemic in certain areas and one acquires the disease when one travels to that area. For example, if one wades through or swims in a river, which is known to be infected with schistosomiasis, one can get

Summary:
In summary I present the case of age,occupation,name ,presenting complaints with duration and any other important detail
Example: I present the case of a 32 year old labourer, Kwesi Mensah who presents with a day’s history of Haemoptysis-5 days, history of chest pains-2 months duration and 3 month history of weight loss.

Question 32

In the history if the patient says I have allergies,arthritis,catarrh,fits,dizziness what can they mean by these symptoms and state some useful distinguishing features

Answer 32

Common underlying problems
Useful distinguishing features
If Allergy it could be a True allergy (immunoglobulin E-mediated reaction) or Intolerance of food or drug, often with nausea or other git upset
Useful distinguishing features :
If it’s a true allergy you’ll see a Visible rash or swelling, rapid onset

If it’s food intolerance or drug intolerance you’ll see Predominantly gastrointestinal symptoms

Indigestion:
It could be Acid reflux with oesophagitis or Abdominal pain due to:
Peptic ulcer
Gastritis
Cholecystitis
Pancreatitis
If it’s acid reflux then the person will have Retrosternal burning, acid taste
If it’s abdominal pain ,the Site and nature of discomfort:
Epigastric, relieved by eating Is the symptom for PUD
Epigastric, with vomiting for gastritis
Right upper quadrant, tender for cholecystitis
Epigastric, severe, tender for pancreatitis

Arthritis :
It could be Joint pain or Muscle pain or
Immobility due to prior skeletal injury
If joint pain,Redness or swelling of joints
If muscle pain,Muscle tenderness
If the third one ,you’ll see Deformity at site

Catarrh :
It could be Purulent sputum from bronchitis or
Infected sinonasal discharge or
Nasal blockage
If it’s the first one you’ll see Cough, yellow or green sputum
If second one, Yellow or green nasal discharge
If third one, Anosmia, prior nasal injury/polyps

Fits :
It could be Transient syncope from cardiac disease or
Epilepsy or
Abnormal involuntary movement
If it’s the first one you’ll see ,Witnessed pallor during syncope
Second you’ll see;Witnessed tonic/clonic movements
If last one you’ll see,No loss of consciousness

Dizziness :
It could be Labyrinthitis or
Syncope from hypotension or
Cerebrovascular event
If first one you’ll see
Nystagmus, feeling of room spinning, with no other neurological deficit if Second one you’ll see History of palpitation or cardiac disease, postural element if third one you’ll see
Sudden onset, with other neurological deficit

Question 33

Explain the SOCRATES POINTS for checking characteristic of pain

Answer 33

Characteristics of pain (SOCRATES)
Site:
• Somatic pain, often well localised, e.g. sprained ankle • Visceral pain, more diffuse, e.g. angina pectoris

Onset:
• Speed of onset and any associated circumstances

Character:
• Described by adjectives, e.g. sharp/dull, burning/tingling, boring/ stabbing, crushing/tugging, preferably using the patient’s own description rather than offering suggestions

Radiation:
• Through local extension
•Referredbyasharedneuronalpathwaytoadistantunaffectedsite,e.g.
diaphragmatic pain at the shoulder tip via the phrenic nerve (C3, C4)
Associated symptoms
• Visual aura accompanying migraine with aura
• Numbness in the leg with back pain suggesting nerve root irritation

Timing (duration, course, pattern):
• Since onset
• Episodic or continuous:
• If episodic, duration and frequency of attacks • If continuous, any changes in severity

Exacerbating and relieving factors:
• Circumstances in which pain is provoked or exacerbated, e.g. eating
• Specific activities or postures, and any avoidance measures that
have been taken to prevent onset
• Effects of specific activities or postures, including effects of
medication and alternative medical approaches

Severity:
• Difficult to assess, as so subjective
• Sometimes helpful to compare with other common pains, e.g.
toothache
• Variation by day or night, during the week or month, e.g. relating to the menstrual cycle

Question 34

How’d you approach sensitive questions with a patient

How do you deal with emotional or angry patients?

Answer 34

Doctors sometimes need to ask personal or sensitive questions and examine intimate parts. If you are talking to a patient who may be suffering from sexual dysfunction, sexual abuse or sexually transmitted disease, broach the subject sensitively. Indicate that you are going to ask questions in this area and make sure the conversation is entirely private. For example:
Because of what you’re telling me, I need to ask you some rather personal questions. Is that OK?
Can I ask if you have a regular sexual partner?
follow this up with:
Is your partner male or female?
if there is no regular partner, ask sensitively:
How many sexual partners have you had in the past year?
Have you had any problems with your relationships
or in your sex life that you would like to mention?
If you need to examine intimate areas, ask permission sensitively
and always secure the help of a chaperone. This is always required for examination of the breasts, genitals or rectum, but may apply in some circumstances or cultures whenever you need to touch the patient (

and seek the assistance and presence of another healthcare worker as a witness for your own protection.
Talkative patients or those who want to deal with many things at once may respond to ‘I only have a short time left with you, so what’s the most important thing we need to deal with now?’ If patients have a long list of symptoms, suggest ‘Of the six things
you’ve raised today, I can only deal with two, so tell me which are the most important to you and we’ll deal with the rest later.’ Set professional boundaries if your patient becomes overly familiar: ‘Well, it would be inappropriate for me to discuss my personal issues with you. I’m here to help you so let’s focus
on your problem.’