Lecture Slides Presented at SIMS by Medical Unit SIMS Hospital

1. Objective to address a provisional diagnosis
Diagnosis stands for
History Exam Investigation

2. HISTORY : An analysis of primary information to
understand the ongoing pathology in a sequential
order & this is
Medicine – A problem solving activity,
An academic exercise towards solution
Through brain storming.

3. CONTENTS OF HISTORY
1) Introduction
2) P/C
3) HOPI
4) Past history
5) Treatment history
6) Personal
7) Family
8) Social economic history

4. Introduction means to know about
Name- Age -
Residence Occupation

5. PRESENTING COMPLAINT
Access through
Open enquiry
Closed enquiry
Closed enquiry stands for three issues
A. Clarification
B. Reflection
C. Summary

6. Aims & objectives of P/C
1. To keep history in flow
2. To indentify issues which needs further elaboration
3. Should be able to put a symptom (chief complaint)
into a certain system.
4. Therefore to plug the right complaint with reference
to a system is the main objective.

7. Symptoms of GIT
Patient has a habit to give a diagnosis in very
beginning or use vague terms, like in digestion,
hyperacidity, flatulence etc, so needs to be
discouraged. Symptoms are so many like ----------

8. HISTORY OF PRESENTING ILLNESS
 Extremely important part of history. Here a medical
student is judged for
1. Communication skill
2. About the depth of knowledge i.e core knowledge
3. About the breadth of his knowledge i.e his vision
about the problem- D/D ---------
4. Medical Students has been Judged for his ability to
address a logical conclusion/provisional diagnosis of
presenting complaint.

9.  A brief review of past history like known patient of
CLD, Known patient of APD, known patient of IBD, etc
can be pasted before the HOPI.
 An important clue to understand the ongoing
problem.
 Most of the time the patients presenting complaint has
been related with his known illness.

10. OPENING SENTENCE OF HOPI
 Is about initial status of patient that how long he was
absolutely all right or
 in usual state of health ------------

11. FORMAT OF HOPI
1. Symptom evaluation and its associations
2. Working diagnosis
3. Differential diagnosis
4. Systemic enquiry

12. SYMPTOM EVALUATION
1. Symptom evaluation means complete elaboration of
chief complaint in terms of onset, duration, progress
aggravating / Reliving factor ----- etc & then
associated features of presenting complaint
Objective is to explain features of P/C against a
certain system.

13. WORKING DIAGNOSIS
 Here the doctor ability has been assessed to give a
working diagnosis only through a history, means to be
explain under a system.

14. DIFFERENTIAL DIAGNOSIS
 This portion of HOPI is to access you span/vision
weather you are able to give other possibilities which
closely mimic to your diagnosis through analysis of
P/C

15. SYSTEMIC INQUIRY
 Here a medical students has been accessed whether he
knows about the effects of presenting complaint on
the rest of the systems.

16. PAST HISTORY
 Importance of brief review of past before history of
presenting of illness -------
 Here the brief review in the very beginning needs
further elaboration in terms of hospital admission
serious ailments, even the suffering since childhood
needs to be explained here.

17. IMPORTANCE OF THE PAST HISTORY
 Although it is small part of the history but very much
sportive for the present diagnosis which have been
explained in the history of presenting illness.
 It may not only change the present diagnosis but may
influence whole treatment scenario.
 Explain in terms of examples.

18. PULMONARY COCK’S
 A past history of pulmonary tuberculosis may indicate
1. Re-activation / re-infection of tuberculosis .
2. Simply patient may come with the same disease due to
non compliance.
3. A sufferer of MDR -------- needs dot therapy

19. HISTORY OF CHOLECYSTECTOMY
 Patient might have the presenting complaint of burbs ,
flatulence or upper abdominal discomfort .
 Here this support of the past history may change the
treatment because her the patient simply needs the
explanation how to live without gallbladder
 Primarily a dietary advise.

20. RECENT HISTORY OF SURGERY/
INFECTION OR VACCINATION
 Presenting complaint--------- paraplegia
 Most likely diagnosis is GB syndrome.

21. HISTORY OF BLOOD TRANSFUSION
 May be since childhood
 A clue for congentinal haemolytic anemia.
 May present with complication of repeated blood
transfusion -------.

22. MAY PRESENT OF WITH UTI
 History of the urethral discharge/venereal exposure
ended with the diagnosis HIV .
 There are so many examples to code which may
influence not only the presence status but also change
the treatment sunerio .
 So this small part of past history is quite significant.

23. TREATMENT HISTORY
 Now again a Caring part of his
 which not only have a dire consequences of patient
health/life but open new avenue of investigation or
even become a charter of crime.
 Patient sometimes not know about drugs so advise to
bring drugs taken / prescriptions needs to be
evaluated.
 Even acquire details about Hakeem medication
kushtas- ARSENIC INTAKE

24. NON COMPLIANCE
 Patient may come with uncontrolled BP/DM ,
 compliance is the issue / not diagnosis, so counseling
is required. Rather change of treatment .
 Some docs just change the dose without knowing
previous management – it is quite dangerous.

25. DRUG ALLERGY
 Treatment is important regarding H/O drugs allergy/
Anaphylaxis /Serious side effects, like diarrhea,
palpitation, broncho spasm ext. So this information in
history will change your treatment plan.

26. BLEEDING TENDENCY
 Patient may come with the complain of bloody
vomiting or generalized bleeding tendency may be due
to decreased cell lines or decreased platelets because
of some medication like warfarin therapy , excessive
use of disprin or H/O chloramphinicol /
Antineoplastic drugs/ Anti malarial like
pyramethamine may cause such problem..
 as recent incidence of PIC in last year where many
patients have suffered because of bone marrow
suppression- presented with bleeding tendency due to
there Anti-co-agluents /statin.

27. MENSTRUAL HISTORY
 There the various symptoms regarding menstrual
history like dysmenorrhae ,Menorhegia/ Leading to
Anaemia/ most likely diagnosis is for endocrinal
disorder.
 Similarly a patient come to you with the complain of–
Migrain /epileptic fitts have a diagnosis of catamenial
epliepsy,

28. PERSONAL HISTORY
 Important in terms of Social & Civil Circumstances,
which may influence the health so it is addressable
under various subheading.

29. ADDICTION
 Person must be asked about any type of addiction
because this part of history may favour diagnosis or
current problem.
 Addiction may be in terms of alcohol, smoking,
Narcotic Abuse including I/V liners even H/O Pan,
Niswar or Gutka intake to be asked.

30. TWO ISSUES ARE IMPORTANT
 How much i.e quantity & how long i.e duration
Peripheral vascular disorder
COPD, CA lung etcToxic amblyopia

31. TWO ISSUES ARE IMPORTANT
 How much i.e quantity & how long i.e duration
These complications depends upon duration quantity.
PHYCOSIS
Proximal myopathyNeuropathy
CMP
Wernicke’s
encephalopahty an
(acute emergency)

32. DOMESTIC/ MARITAL RELATIONSHIP
 Including Hobbies and different phycological ailments
are the by product of these issues.

33. TRAVEL ABROAD
 May expose the person to different disease like yellow
fever, sleeping sickness, schistosomiasis or exposure to
venereal diseases

34. FAMILY HISTORY
 This part of the history is important in terms of
patient marriage status, numbers of children and their
health status including any history of serious ailment
from his father and mother side.
 Here we are more concerned about the potentially
inherited disorders.

35. AUTOSOMAL DISORDER
 Genetic basis is quite striking like asthma in which
autosomal recessive character although less apparent
but have a definite roll in the spread of disease
particularly in OAD.
 Next pattern of inheritence in families is about
autosomal dominant chraracter like huntingtons
chorea or congenital haemolytic anaemias.
 Here we have to discourage about the issue of cousin
marriage if the family history exist.

36. X LINKED DISORDERS
 Here we are more concerned with the sex linked
disorders particularly the diseases effecting over X
chromosome.
 So haemophelia and vonwillibrand disease are the
notorious X linked diseases.
 Here females are carrier and males are the sufferers.

37.  In many common disorders like CHD, DM, HTN and
dyslipidemia/Atheroma, the mode of inheritance is
quite complex and influencet by environmental effects
like diet, smoking, obesity and sedentary life style
including the depressive illness in families which affect
over the outcome of diseases.

38. OCCOUPATIONAL HISTORY
 Here the exact nature and description of job should be
asked, not only the present but also past history of job
should also be enquired.
 In many diseases occupation is directly related to the
present illness. Although nature of occupation has
been asked in the very beginning during introduction
but here it should be evaluated in detail.

39.  Most of the time respiratory diseases are the biproduct
of occupational hazards. These depend upon the
duration of exposure.
 For example ILD is quite common among coal miners.
Similarly cotton industry may expose the labourer to
OAD.
 Brucellosis is quite common in farmers dealing with
cattles.
 Organophosphate poising is quite common among
villagers particularly working on cultivated land .

40. SOCIOECONOMIC HISTORY
 This part of the history important in sense of
affordability whether the person is able, either to get
the treatment or not.
 Statistically certain diseases are more prevailing in
different social circles like tuberculosis , C viral disease
etc are more common in lower income group.

41. SUMMARY OF THE HISTORY
 At the end of the history, medical students has been
asked to summaries the history it means
 A medical students should know how to explain
briefly about different aspects of the history
 Including introduction of patient, his presenting
complaint in terms of likely diagnosis , a few
differential and relevant systemic inquiry should be
explained briefly.

42. General physical examination
 For the general physical examination we have to have a
certain sequagel.
 Through the sequence of general physical examination
the first and foremost issue is
To get the consent of the patient for examination.
• Here the doctor has to introduce him self and has to
explain the patient, for what purpose doctor want to
examine the patient.
• This consent is very important in the sense the doctor
has to make a physical contact for examination.
Therefore the patient should be comfortable and
confident for examination.

43. POSITION OF THE PATIENT
 Every system of the body has been examined through
making a definite position of the patient for the said
system which should be convenient not only for the
patient but also for the doctor.
 For GIT the patient should lie in supine position with
the hands along the side of the body.

44. EXPOSURE OF THE PATIENT
 The person should be exposed properly for
examination
 In GIT, the person should be exposed up till the mid
chest and bellow up till the groins.
 But remember one thing, exposure does not mean
indecent exposure but take into account the
socioeconomic, cultural and religious norms of the
society.

45. VISUAL SURVEY OF THE PATIENT.
 Always approach to the patient on the right side and
after taking consent, make the position, do the proper
exposure and get
 An aerial/ panoramic view of the patient from head to
toe then come to foot end of the patient, sit at the level
and do the same exercise.
 During the visual survey you have to notice the
following issues.

46. 1. Appearance of the patient
2. Apparent age
3. Nutritional status
4. Level of consciousness
5. Behavior of the patient
 Therefore the doctor has to comment about these five
expects during the aerial view.
 For example, you can make statement like this
 A cooperative middle age male looking emaciated
lying on bed comfortably well oriented in time place
and person.

47. VITALS OF THE PATIENT
 Regarding vitals doctor has to comment about
1. Pulse
2. B.P
3. Temp.
4. R R
5. After taking the vital doctor has to summaries the
statement like pulse is 76/min. Regular in rhythm
patient is narmotensive, afebrile, while
respiratory rate is 16/min.

48. Signs of the patient
• Doctor is required to check the following signs for
general physical examination.
1. Anaemia
2. Jaundice
3. Cyanosis
4. Edemia
5. Clubbing
6. Lymph nodes

49. Anemia
 By definition when hemoglobin level is below the
normal range with respect to patient age and sex
 Sites for anemia
 Anemia has been checked over skin, mucous membrane,
Conjunctiva and over the palms /nails.
 Rest of the sign depends upon the severity and type of
anaemia but in general physical examination one has to
comment simply over the presence of anaemia.
 The main symptoms are tiredness , fatigability , SOB,
heavy headedness and palpitation.

50. JAUNDICE
 It is the yellow pigmentation of skin and sclera.
 Caused by elevation of serum bilirubin.
 Clinically jaundice is evident when serum bilirubin
level is more then 2 to 2.5mg/dl collectively.
 Sites for Jaundice .
 Skin
 Palmer Creases
 Sclera
 Pathologically Jaundice is classified as
 Non obstructive
 Obstructive jaundice

51. OEDEMA
 By defination oedema means accumulation of fee fluid
in interstitinal space.
 as you know body fluid is present in two
compartments .
 Vascular
 Extra vascular
Extra vascular is further divided into two compartments.
intera cellular
Extra cellular/ interstitial fluid.
Clinically patient may come with complain of swelling mainly over
the extremities .
This swelling may be localized or generalized.

52. Nature of swelling
 If the swelling has indentation at the site of pressure,
It is called pitting in nature now it may be sign or
symptoms.
 If swelling has no indentation, it is called non pitting
oedema .
 It can be explain through various examples and the
accumulation of fluid is due to increased hyodostatic
pressure in both pitting and non pitting oedema.
 It may be due to decreased oncotic pressure

53. Sites
 Dorsum of foot
 Distal/3 of tibia
 Sacrum
 Bellow medial malleolus.
The pressure of finger at the said site should be
maintained at least for thirty seconds.

54. Etiology
 It is variable
 If it is due to increased hydrostatic pressure then the
causes are
 CCF
 Constrictive pericarditis.
 Cor-pulmonale
 Drugs
 Iatrogenic

55.  Decreased oncotic pressure may be due to.
 CLD
 Nephrotic syndrom
 Malabsorption

56. Cyanosis
 By definition it is a bluehes discoloration of skin and
mucous membrane due to
 Ecessive accumulation of reduced Hb in blood at least
5gm/dl of reduced Hb.
 In severe anemia cyanosis may be absent.
 In polycythemia it may occur quickly.

57. Types
 Central because of systemic insult.
 Main cause is inpimpaired oxygenation of blood.

 Defective ventilation/ perfusum due to respiratory
disease.
 Admixture of deoxygenated blood that is venous into
systemic circulation e.g reversal shunt in congenital
heart diseases like VSD/ fallots tetrollogy/ SBE.

58. Peripheral cyanosis
 It is vascular in origin e.g raynauds
phenomenon/raynauds disease.
Sites.
Peripheral cyanosis has been seen over extremities which
are cold and by warning cyanosis may become absent.
Central cyanosis
Central cyanosis has been checked over extremities which
are warm and in mucous membrane that is under
surface of tongue and tip of Nose.

59. Clubbing
 It is a morphological change in the shape of nails.
 Normaly nails are curved from the side to side and
straight longitudenaly.
 Normaly there is an angle between nail bed and soft
tissue junction seen as a gap if straight line is drawn
bridging the cuticle and soft tissue.

60. Pathology and grades of clubbing
 Pathologically there is deposition of vascular spongy
tissue.
 Grades
 Grade - 1.
 Spongy tissue is deposited is under nails angle which has been
obliterated – GAP absent.
 Grade -2.
 Nails become convex from side to side and from above downward
and the shape of the nails may become like inverted spoon.
 Grade -3.
 Terminal phalanges will become drumstick appearance.

61.  Grade -4
 Disease may extend to lower and of long bones causeing
painful swelling of wrist at the lower ends of radius and
ulna called pulmonary osteodystrophy .
 In the examination of GIT, clubbing is not so common
but only present in malabsorption syndrom.