How to take a medical history and examination for Cov-Ed

1. Medical History & Examination
Cristina Fernandez
NMGH
March 2020

2. Lecture outline
 Overview of the medical history
 Focus on what to cover in a respiratory history
 Respiratory examination
 Cardiovascular examination

3. The medical history
Traditional framework:
1. Presenting complaint
2. History of presenting complaint
3. Past medical history
4. Allergies
5. Medication history
6. Social history
7. Systems review
8. Family history
9. Opportunity for questions
• In practice, history taking is never such a rigid
process. Most clinicians will develop their own
style over time, and will be able to adapt it when
needed.
• Specifics aspects to not miss in patients with query
COVID-19
1. Assessment of breathlessness, fever & cough
2. Detailed history of any previous or chronic lung
disease
3. Detailed assessment of function and
performance
4. A clinical frailty scale assessment
5. Exploration of patients understanding of their
condition and expectations regarding their
hospital stay and medical management

4. Presenting symptom(s)
You should use an open question to establish this:
“What has brought you in?”, “Why are you here
today?” “What seems to be the problem?”
A common, well-known mneumonic to better explore
a patient’s pain as their presenting complaint is
SOCRATES.
• S Site
• O Onset
• C Character
• R Radiation
• A Alleviating factors
• T Timing
• E Exacerbating factors
• S Severity
Consider risk factors for the patient’s presenting
complaint
• Cardiovascular risk factors: smoking, hypertension,
diabetes, hypercholesterolaemia, family history of
cardiovascular disease or sudden death
• Respiratory risk factors: smoking (personal history
and passive), occupation (previous and current
occupations are important), drug use, family
history of respiratory problems, asbestos exposure,
unwell contacts, pets / animal exposure

5. Past medical history
This should be an exhaustive list of all the patients medical conditions, major illnesses, previous
surgery/operations, trauma.
Chronic conditions require an assessment of duration, severity, current management and
complications
e.g. in a diabetic patient you will need to establish how long they have been diagnosed,
what treatment(s) they are on, how good their usual control is, if they have ever been hospitalised
due to their diabetes, and if they have any end-organ damage as a consequence of diabetes.
Questions you could use if patients are unsure of their past medical history are:
“What do you usually visit your GP for?”
“Is there anything you have been to see a doctor in hospital about in the past?”
“Have you ever been admitted to hospital for anything?”
“If you take any regular medication, what is this for?”

6. Allergies and medication history
• ALWAYS enquire about allergies and make a record of the exact
reaction to the medication
• Document this in the electronic prescribing system if not present
there already
• A detailed drug history should include prescribed medication (tablets,
injections, creams, inhalers), over the counter medication, and
previous and current recreational and intravenous drug use

7. Review of systems
List of major systems
Constitutional: fatigue, weight, fever, appetite, sweats
Eyes
Ear, nose, throat, mouth
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Endocrine
Haematological / Lymphatic
• How exhaustive a review of
systems you perform will be
dictated by the information you
have already obtained and time
constraints. In some circumstances
a more focused history is required
that will not be able to cover a
comprehensive review of systems.
• An open question to start this
section off may be helpful (e.g. “Is
there anything that you feel is
important to mention that I haven’t
asked already?”)

8. Function & performance
• Functional status: A person’s ability to perform tasks that are required for living.
• These will include self-care activities (eating, dressing, bathing, transferring between the bed and
a chair, using the toilet, controlling bladder and bowel functions) and activities needed to live
independently (doing housework, preparing meals, taking medications properly, managing
finances, using a telephone)
• Performance status: Usually used in cancer care to establish a patient’s general
wellbeing. In a medical history it is important to determine:
• Patient’s exercise tolerance: How far are they able to walk on the flat? Are they able to manage
stairs? How often do they leave the house and what for? Do they use any walking aids? You could
refer the the MRC dyspnoea scale to document this.
• Effect of chronic and acute symptoms on ability to perform activities of daily living and exercise
tolerance
• The information you obtain in this section will help make a Clinical Frailty Scale
assessment
• This is important to determine prognosis and escalation decisions for patients with
COVID-19

10. Respiratory history
Common presenting
symptoms
Details to be enquire about
Dyspnoea Duration, usual and current exercise tolerance (can use MRC dyspnoea score to
assess severity of breathlessness), presence of dyspnoea at rest, exacerbating
factors or triggers, added breath sounds (e.g. wheeze), medications/inhalers used
so far, presence of orthopnoea, associated leg swelling, presence of
cough/fever/constitutional symptoms.
Cough Duration, character of cough, exacerbating factors or triggers, sputum production
(colour, amount), presence of haemoptysis, associated chest pain, presence of
cough/fever/constitutional symptoms.
Fever Duration, severity of fever, associated rigors, diurnal variability
Other symptoms to
enquire about
Chest pain, night sweats, weight loss, fatigue, anorexia.

11. What not to miss in a respiratory history
• Previous / current respiratory conditions: asthma, pneumonia, COPD, PE,
lung neoplasm, cardiothoracic surgery
• Previous ITU admissions
• New drugs: some may exacerbate respiratory problems (e.g. ACE inhibitors,
beta blockers, amiodarone)
• Recent antibiotic use
• Unwell contacts
• Smoking history
• Recreational drug history
• Pets and animal exposure
• Occupational history, asbestos exposure
• Travel history

12. The medical examination
• This is not a comprehensive guide to pass the medical OSCE or PACES,
simply an overview of what not miss when examining patients in the
emergency department or medical assessment unit.
• Basic structure of examinations:
1. General inspection of the patient: age? do they look unwell? are there any
clues around their bed space? obvious signs from bedside
(colour/cachexia/cough/respiratory sounds)
2. Start with the hands -> arms (think observations) -> head and neck
3. Inspect, Palpate, Percuss (in a resp exam) and auscultate
4. Inspect the legs

13. Respiratory examinationHands
Tar staining
Clubbing
Peripheral cyanosis
Skin changes
suggestive of long
term steroid use
Tremor: fine (β 2
agonist use) or
flapping (CO2
retention)
Arms
Pulse: rate &
rhythm
Blood pressure
Pulse oximetry
Respiratory rate
Head&Neck
Pallor
Central cyanosis
JVP

14. Respiratory examinationInspectionofthorax
Scars: front, side
and back
Obvious chest
asymmetry: at
rest and during
respiratorion
Chest
deformities
Palpation
Tracheal
deviation
Location of apex
beat
Chest expansion
Percussion
Ensure you
percuss
bilaterally in: the
supraclavicular
area,
infraclavicular
area, 3 locations
on the chest wall
and the axilla
Ausculatation
Quality: vesicular
(normal) or
bronchial (harsh)
Volume: absent,
quiet or normal
Added sounds:
wheeze, crackles,
pleural rub

15. To complete the examination
• Lymph node exam: cervical and axillary
• Legs: pitting oedema, calves for signs of DVT

16. Respiratory cheat sheet
Consolidation (e.g. pneumonia)
Movement of affected side may be reduced
Dull to percussion
Bronchial breathing
Added sounds: crackles
Pleural Effusion
Trachea may be displaced AWAY from effusion
Movement of affected side may be reduced
Stony dull to percuss
Reduced breath sounds
Reduced vocal fremitus and resonance
Lung collapse
Trachea may be displaced TOWARDS the side of
collapse
Movement of affected side may be reduced
Reduced breath sounds on affected side
Pneumothorax
Trachea is displaced AWAY from the affected side if
there is a tension pneumothorax
Hyper-resonant to percussion
Reduced breath sounds on affected side

17. Cardiovascular examinationHands
Splinter
haemorrhages &
other (less
common) signs of
infective
endocarditis
Clubbing
Tar staining
Arms
Pulses: rate,
rhythm, radio-
radio delay
Blood pressure:
absolute values
and pulse pressure
(narrow or wide)
Respiratory rate
Pulse oximetry
Headandneck
JVP
Conjunctival pallor
Central cyanosis
Dental hygiene

18. Cardiovascular examination
Inspection
Scars: front &
sides
Chest wall
deformities
PalpationApex beat
Heaves & thrills
Auscultation
Auscultate the
four valves (as in
diagram)
Assess for
radiation of
murmurs: aortic
stenosis to
carotids, mitral
regurgitation over
mitral area
A P
T
M
AORTIC
Right sternal
edge, 2nd
intercostal
space
TRICUSPID
Lower left sternal
edge, 4th/5th
intercostal space
MITRAL (APEX)
Midclavicular line,
5th intercostal
space
Pulmonary
Left sternal
edge, 2nd
intercostal
space

19. To complete examination
• Auscultate the lung bases
• Legs: scars, chronic changes, pitting oedema