History Taking by The Medical Post


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History Taking for Medicine & Surgery

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History Taking by The Medical Post

  1. 1. History Taking History taking in Medicine and Surgery for final MBBS practical exams FIRST EDITION The Medical Post (www.themedicalpost.net)
  2. 2. History Taking Cerebrovascular Accidents (Stroke) Common presenting complaints –    Weakness on one side of the body. Facial deviation or asymmetry. Loss of consciousness. History of presenting illness – In such cases the history should ideally start as my patient was apparently asymptomatic _ days back when he developed weakness on one side of the body. The weakness was acute/insidious in onset and gradually progressive/static in nature. Mention what activity the patient was involved in at the time when this weakness developed. Whether the patient fell down and hurt themselves as the attack occurred. Important points during the pre ictal phase: Any history of headache, vomiting, dizziness. Facial deviation: Ask to which side the angle of mouth/face is deviated, any history of slurred speech, drooling of saliva, difficulty in drinking liquids and regurgitation of food after the stroke attack. Seizures: History of abnormal body movements, tongue biting, up rolling of eyes and frothy secretions from the mouth. Embolic evidence – History of chest pain, dyspnea and palpitations. The Medical Post (www.themedicalpost.net)
  3. 3. History Taking Incontinence of stools and urine. Blurring/loss of vision. Any history of recent head injury/trauma. Past history – Rule of any previous episode of TIAs. Any similar episodes in the past. Any history of significant medical condition in the past. Predisposing factors like Hypertension, Diabetes, Smoking, and Alcohol. History of intake of drugs like OCPs, Aspirin, Warfarin, Hormones, etc. Family history of stroke. Ideal CNS Diagnosis: The Medical Post (www.themedicalpost.net)
  4. 4. History Taking Chronic Obstructive Pulmonary Disorder Common presenting complaints –   Sudden increase in the shortness of breath Cough (More with patients of Chronic Bronchitis) History of presenting illness – There are two ways to present a case of COPD. Either start the history dating back to so and so years when the first episode of SOB occurred, or you could present the acute episode first by saying how many days back the patient was apparently asymptomatic plus with elaboration of the previous episodes in the past history. Shortness of breath: Onset (usually insidious) - initial MRC grading – progression (usually there is sudden progression to the current condition) – current MRC grading. Ask for Orthopnea and PND to rule out any cardiac cause. Cough: Onset, progression, about sputum (Cases of chronic bronchitis may complain of cough as their chief complaint), hemoptysis. Associated chest pain? Ask for any seasonal variation/ exposure to air borne irritants on the job. Fever: Onset, pattern, maximum temperature recorded or not, associated with chills and rigors? A patient of COPD usually presents in acute exacerbation either because of infection or rupture of emphysematous bullae. History of weight loss and loss of appetite. (Note that emphysematous patients are usually thin built). The Medical Post (www.themedicalpost.net)
  5. 5. History Taking Any history of bluish discoloration of the generalized skin. (For features of hypoxia). Complication: History of tremors (salbutamol use). Ask for bowel habits (constipation because of hyperkalemia). Headache, mental confusion (features of CO2 narcosis). Personal history: Whether the patient smokes? Duration of smoking. Calculate the number of pack years. Number of pack years = (number of cigarettes smoked per day × number of years smoked)/20 (1 pack has 20 cigarettes). If quit smoking – Why and When did he quit? Family history of similar illness. Past history: Number of episodes in the past. Drug intake – mention all the drugs the patient is currently taking. How the patient’s condition is affecting his/her quality of life: missed work, disrupted routines and depression. Ideal Respiratory System Diagnosis: The Medical Post (www.themedicalpost.net)
  6. 6. History Taking Alcoholic Liver Disease Common presenting complaints –   Yellowish discoloration of the skin. Abdominal distension. History of presenting illness – Yellowish discoloration: Onset, progression (usually it is first noticed in the sclera and then it becomes evident on whole of the body). Abdominal distension: Onset, progression. Associated abdominal pain and difficulty in breathing (as massive ascites pushes the diaphragm up and makes difficult for the patient to take deep breaths). Upper GI Bleed – History of Hematemesis. Hepatic Encephalopathy: Ask the patient party for any history of disorientation/restlessness, tremors, excessive sleep. History of foul smelling odor; fetor hepaticus. Alcohol withdrawal: mental confusion, irrelevant speech, agitation /aggressiveness. Ask any history of loss of hair. Also rule out features of congestive cardiac failure from history. Personal history: History of intake of alcohol – duration of drinking – current situation. History of intravenous drug abuse. The Medical Post (www.themedicalpost.net)
  7. 7. History Taking Bowel habits – pale stools (obstructive jaundice), black tarry stools (portal hypertension). Urine – Dark in color? (Suggesting obstructive jaundice). Past history: Similar episodes in the past. History of hepatitis in the past. Ideal Diagnosis – The Medical Post (www.themedicalpost.net)
  8. 8. History Taking Rheumatic Heart Disease Common presenting complaints –   Shortness of breath Hemoptysis History of presenting illness – Shortness of breath: Onset (usually insidious) - initial NYHA grading – progression (usually there is sudden progression to the current condition) – current NYHA grading. Ask for Orthopnea and PND (orthopnea indicates more severe disease). Cough: Onset, progression, about sputum. (Cases of chronic bronchitis may complain of cough as their chief complaint). Associated chest pain? History of palpitations. Swelling of both the limbs: (due to congestive cardiac failure/RHF). Explain about the onset, progression. Abdominal distension / abdominal pain. History of dizziness/syncope/loss of consciousness/fatigue – due to decreased cardiac output. Personal history: Smoking- Diabetes – Hypertension – Exercise habits – Eating habits. Family history of similar illness. The Medical Post (www.themedicalpost.net)
  9. 9. History Taking Past history: History of similar episodes in the past – number of hospital admissions. History intake of intramuscular penicillin injections every 21 days or intake of Phenoxybenzyl penicillin 250 mg PO BD in the past. Ideal diagnosis – The Medical Post (www.themedicalpost.net)
  10. 10. History Taking Thyroid Swelling / Thyrotoxicosis / Multi nodular Goitre XYZ 57 years old female come from Palpa to the Manipal Teaching Hospital on 09/05/2010 and was examined by me on 13/05/2010 The chief complaints were: Rapid increase in the size of the swelling with pain in the mid line of the neck for the past 2-3 months. History of presenting illness: The history dates back to 30-40 yrs back when the pt noticed a small marble sized swelling on the left side near the mid line of the neck at the age of 16 yrs in the mirror and also when told the neighbor. Initially the swelling was not associated with pain and was stationary and after 16 yrs interval the pt noticed similar welling on the right side of the neck which was also stationary and also not associated with pain. But since the last 2-3 months there has been rapid increase in the size of the swelling on the both side and its associated with pain which is insidious in onset intermittent, dull aching type and radiating towards the back of the neck and the upper back of the shoulder. The pain was relieved on rest and no aggravating factors were found. No history of other swellings in the body, no difficulty in swallowing solid of liquid food, no difficulty in breathing, no hoarseness of voice, no loss of appetite, no loss of weight, no diarrhea or constipation. No history of chest pain, palpitations, nervousness, irritability, difficulty in sleeping, no tremors and no weakness of the limbs, no heat or cold intolerance, no sweating, no decreased or double vision, no ocular pain or redness. The Medical Post (www.themedicalpost.net)
  11. 11. History Taking Past history: No history of TB, DM, HTN, Asthma. No history of surgery or any prolonged hospitalization. Personal history: Non smoker, non alcoholic, normal bowel bladder and sleep habits. Family history: No similar swelling among the family members seen but however there has been significant number of women suffering from similar neck swellings in the locality. Menstrual history: The pt. attended menopause at the age of 40, no history of post menopausal bleeding or any per vaginal discharge. Treatment history: The pt. has not received any treatment for this condition. The pt. has been planned for surgery. EXAMINATION The pt. is moderately built, well alert, cooperative and well oriented to time place and person. The Vitals were in the normal range. There is no pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy. The Medical Post (www.themedicalpost.net)
  12. 12. History Taking Local examination of the Neck1. InspectionThe swelling moves up and down with deglutition.Does not moves with the protrusion of the tongue. The swelling is situated infront and side of the neck extending laterally uptill the sternocleidomastoid muscles and below upto the suprasternal notch and involves whole of the front of the neck. Both the lobes of the thyroid glands are enlarged and the right lobe appears to be more prominent. The right lobe is about 10*8cm and the left lobe about 7*6cm. Trachea is not visible. Dilated veins are seen at the lower border of the swelling. 2. PalpationI confirmed my inspection findings. No raised temperature, No tenderness. Swelling moves with deglutition. The swelling is heart shaped.Size- Rt lobe – 13cm vert. and 9cm horz. Lt lobe is 9cm and 7cm respectively., Isthmus is 10cm vertically. It is variable in consistency. Margins are well defined.-Trachea not palpable.Skin over the swelling can be pinched out. No pulsations and thrill were felt. Mobility is present from side to side and not vertically. Swelling is attached to the sternocleidomastoid muscle and on making the neck taught the mobility of swelling is restricted. Carotid pulsations are felt at the ant. border of the sternocledomastoid muscle. The Medical Post (www.themedicalpost.net)
  13. 13. History Taking PercussionSuperior mediastinum is resonant. AuscultationNo bruit over the swelling heard. There were no signs of the toxicity present. Special TestKocher test is positive. Pembertant sign is negative. The Medical Post (www.themedicalpost.net)
  14. 14. History Taking Hernia/Hydrocele Common presenting complaints –   [HERNIA] Swelling on the left/right groin since the past _ days/months/years. [HYDROCELE] Swelling on the left/right scrotum since the past _ days/months/years. History of presenting illness – Swelling: Onset (usually spontaneous) – site (left / right groin) - initially of a size similar to some object (e.g. marble), progression (usually gradual to the current size) – extent (groin to the scrotum/scrotum to the groin). Change in the size of the swelling on lying down/standing position. Increase in the size of the swelling on coughing, defecation, etc. Note that in Hydrocele there is no change in the size of the swelling during standing, walking, with strenuous activities or on lying down. Also there is no pain and other symptoms. Features of strangulation/toxicity : Any sudden increase in the size of the swelling. Any color change ? Pain over the swelling. History of vomiting, fever. Pain: site of pain, character, radiation, relation of pain with straining (usually the pain increases on straining), relieving factors. The Medical Post (www.themedicalpost.net)
  15. 15. History Taking History for straining factor (to find the cause of hernia) Cough, Constipation Predisposing factors like – Bronchial asthma, Diabetes, Tuberculosis, Hypertension. Bladder habits: Urgency, frequency, narrowing or irregular urinary stream (features suggestive of BPH). The Medical Post (www.themedicalpost.net)
  16. 16. History Taking Breast Lump Common presenting complaints –   Swelling in the right/left breast. Pain in the breast/ over the swelling. History of presenting illness – Swelling: Onset, site, size, progression. How did the patient notice the swelling (usually on breast self examination). Any swelling in the axilla or the opposite breast. Pain: site, duration, character (usually dull aching), relationship with the swelling and the menstrual cycle. Fever (Swelling, pain and fever are characteristics of breast abscess). Ulcer (usually associated with carcinoma of breast) – explain with site, duration, discharge. Nipple discharge. Any history of loss of appetite and weight. (Suggestive of carcinoma). History suggestive of metastasis Any history of cough, breathlessness, hemoptysis, chest pain. Any history of low back pain, and radiation of pain to the lower limbs. Any history of headache, vomiting, weakness of any limbs, any history of seizures. The Medical Post (www.themedicalpost.net)
  17. 17. History Taking Personal history: Menstrual history – age at menarche. Obstetric history – age at first pregnancy, total number of pregnancy, number of abortion, last child birth. History of lactation. History of use of OCPs or any hormonal therapy. The Medical Post (www.themedicalpost.net)
  18. 18. History Taking Road Traffic Accident Common presenting complaints –    Loss of consciousness/headache following a road traffic accident or fall from height. [HEAD INJURY] Difficulty in breathing. [CHEST INJURY] Drowsy. [SHOCK / BLUNT ABDOMINAL TRAUMA] History of presenting illness – Usually start the history as the following, My patient was apparently asymptomatic 4 hours back when he met with a road traffic accident following which is banged his/her head on the road (in a case of head injury). Details about the accident :       Whether the patient was a driver/passenger/pedestrian. The impact occurred from which side. Wearing a seat belt or not. Did he strike on anything after the accident. If yes then what body parts were involved? Road conditions – dry, wet, snow/ice, banged on the divider? Who brought the patient to the hospital and how? Important history taking in a case of head injury,  Any period of loss of consciousness following the accident. Duration of the period. Any lucid interval present (it means any history of the The Medical Post (www.themedicalpost.net)
  19. 19. History Taking      patient being restless, talkative, irritable, confused, etc. before becoming completely unconscious). Vomiting – usually in a case of underlying head injury there are multiple episodes of vomiting; projectile in nature. (It is because of the raised intracranial pressure). Headache. Blurring or loss of vision following the accident. Prolonged confusion. Abnormal body movements (seizures). In case the patient presents after a few days of the accident, we must ask for if the patient is having difficulty in concentration – increased mood swings – lethargy – aggression – altered sleep habits. Other important points to be asked,  Difficulty in breathing (to rule out chest injury). The Medical Post (www.themedicalpost.net)