HISTORY TAKING Make a diagnosis if possible Formulate a management plan for the patient Explain and discuss this

his with the patient AIM-DEVELOPING A MANAGEMENT PLAN FOR A PATIENT Establish a relationship with the patient Gather information History taking Physical Examination Investigation Patients presenting problem OPEN QUESTIONS WHAT WHO HOW WHERE WHY WHEN MODAL QUESTIONS DO CAN MAY IS WILL SHALL

Basic information about the patient

Family history

Social history

Description of presenting problem

Past medical history

History of presenting problem

Review of body systems

REVIEW OF SYSTEMSTHE NERVOUS SYSTEM CARDIOVASCULAR/RESPIRATORY Headaches SYSTEM Faints,fits,loss of consciousness Numbness/tingling in limbs Cough/Sputum Problems with eyesight/speech hearing Shortness of breath/wheeze Mood, memory, concentration Chest pain Weakness/wasting in limbs Palpitations Ankle swelling ENDOCRINE SYSTEM Polydipsia GASTROINTESTINAL SYSTEM Polyuria Hot/cold tolerance Appetite Hair change Weight change Difficulty swallowing UROGENITAL SYSTEM Heartburn Dysuria Nausea/vomiting Frequency Abdominal pain/swelling Nocturia Bowel Haematuria frequency/consistency/rectal bleeding Men Testicular pain Swelling Problems urinating MUCULOSKELETAL SYSTEM/SKIN Joint pain /stiffness/ swelling/Back pain/Muscle pain /Skin problems

Women Menstrual details Obstetric history Contraception S-site-can you tell me or show me where the pain is? O-onset- have you ever experienced this type of pain before? C-Character-can you describe the pain in your own words?stabbing, throbbing dull, R-RadiationDoes the pain go anywhere else? A-Alleviating factors/associated symptoms What do you do about it when it happens or have you tried to make it better? Did that help? Or is there anything else associated with the pain? T-Timing is the pain constant or does it come and go? How long does it last? E-Exacerbating factorsdoes anything make it worse? S-How painful would you say it is on a scale of one to ten?

Primary History Obtain a detailed history that is complete, accurate and relevant Find out the patients perception of what is wrong Establish their attitudes to the problem Determine what effect the problem has on their day-to-day life and relationships. You should always begin the physician-centered phase of the interview with "WH" questions (where? what? when?) directed at the chief complaint(s). Build on the information the patient has already given you. Flesh out areas of the story you don't fully understand. Try to quantify whenever possible (pain on a scale of 1 to 10, number of days instead of "a while," etc.). Be as specific as possible and try to record what the patient says accurately, without interpretation. Address as many of these details as appropriate: 1. Location 2. Radiation 3. Quality 4. Quantity 5. Duration 6. Frequency 7. Aggravating Factors 8. Relieving Factors 9. Associated Symptoms 10. Effect on Function Secondary History The secondary history expands on the primary history, especially any associated symptoms. It is useful to think of the secondary history as a focused review of systems. These questions often bring out information that supports a certain diagnosis or helps you gauge the severity of the disorder. Unlike the primary history, a certain amount of interpretation (and experience) is necessary. Here are some examples: Headache Ask about nausea and vomiting. Ask about visual changes. Ask about the relationship with stress, work, week-ends, and emotions. Ear Problems Ask about hearing loss or ringing in the ears. Ask about dizziness or vertigo. Tertiary History The tertiary history brings in elements of the past medical history that have direct bearing on the patient's condition. By the time you get to the tertiary history you may already have a good idea of what might be going on. (This will be fine tuned by the physical exam.) Here are some examples:

Any HEENT or Chest Disorder Does the patient smoke? How much? How long? For children, does someone smoke in the home? Breast Problems Is there a family history of breast cancer? Abdominal Pain Does the patient smoke? How much? How long? How much alcohol does the patient consume? Prior surgery? Has the appendix been removed? Chest Pain Does the patient smoke? How much? How long? Did the patient's parents die of a heart attack? At what ages? Review of Systems The review of systems is just that, a series of questions grouped by organ system including: 1. General/Constitutional 2. Skin/Breast 3. Eyes/Ears/Nose/Mouth/Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Neurologic/Psychiatric 10. Allergic/Immunologic/Lymphatic/Endocrine NERVOUS SYSTEM Head aches Faints, fits, loss of consciousness Numbness/tingling in limbs Problems with eyesight/speech/hearing Mood, memory, concentration Weakness, wasting in limbs ENDOCRINE SYSTEM Polydipsia

Polyuria Hot/cold tolerance Hair change

CARDIOVASCULAR/RESPIRATORY SYSTEM Cough/Sputum Shortness of breath/wheeze Chest pain Palpitations Ankle swelling

GASTROINTESTINAL SYSTEM Appetite Weight change Difficulty swallowing Heartburn Nausea/vomiting Abdominal pain/swelling Bowel frequency/consistency/rectal bleeding

UROGENITAL SYSTEM Dysuria Frequency Nocturia Haematuria Mentesticular pain/swelling/problems urinating Womenmenstrual details/obstetric history/contraception

MUSCULOSKELETAL SYSTEM/SKIN Joint pain/stiffness/swelling Back pain Muscle pain Skin problems

Past Medical History The past medical history is essentially background information related to the patient's health and well-being. A brief past medical (and social) history often includes these elements: [] 1. Allergies and Reactions to Drugs (What happened?)

2. 3. 4. 5. 6. 7.

Current Medications (Including "Over-the-Counter") Medical/Psychiatric Illnesses (Diabetes, Hypertension, Depression, etc.) Surgeries/Injuries/Hospitalizations (Appendectomy, Car Accident, etc.) Immunizations Tobacco/Alcohol/Drug Use Reproductive Status for Females o Last Menstrual Period o Last Pelvic Exam/Pap Smear o Pregnancies/Births/Contraception 8. Birth History/Developmental Milestones for Children 9. Marital/Family Status 10. Occupation/Exposures

Questions:
Good morning Mr. XYZ, I am Dr. ABC, one of the physician in this hospital. I am here to ask you a few questions and give you physical examination. Before that let me drape you first so you feel more comfortable Can you tell me the reason for coming to the hospital today? Can you tell me more about it? About pain ( SOCRATES) L: can you tell me where does it hurt? I: on the scale of 1 to 10, 1 being and 10 being the most severe pain, which no. best describes your pain? Q: How would you describe your pain? O: --when did it start? -- How did it start? -- how has it progressed over this period? -- Is it continuous or intermittent? If intermittent --how frequently do u have such episodes? --how long does it last? -- is there anything that might have brought this in? -- What where you doing when this pain started? -- Did you take any medications to get relief? -- Did it help? R: Does it move any where else?

A: is there anything that makes your pain better? A: is there anything that makes your pain worse? W: Have you noticed any change in your weight? How many pounds did you lost? Over what period? Summarize the wt so you have lost 10 pounds in 3 months.. A: How about your appetite? B: How is your bowel function? B: How is your bladder function? Summarize chief complain and other important points Now I will ask a few question regarding your health in past. Is that okay with you? PS- Did you have similar complain in the past? D- Do you have high blood sugar? H Do you have high blood pressure? When was it diagnosed? What do you do to control it (your blood sugar/ blood pressure) Do you remember the name of medication? If patients do not remember the name of medication then ask Do you have prescription of medication? Do you remember dose of medication? Are you taking your medications regularly? Is/are medications taking care of your blood pressure? Do you get your blood pressure checked regularly? Do you have any other medical illness? In old and heart patients ask about cholesterol Have you ever got your cholesterol checked? Was that normal? A: Are you allergic to anything? M : Besides this medication for high blood sugar and blood pressure (glipizide) are you taking any other medications? In case of old female patient usually over 60 ask about

Did you receive any hormonal pills? How about vit-D or calcium supplementation? T: have you ever been involved in major trauma? S: Have you ever undergone any kind of surgery? Did you recover fully? H: Have you ever been hospitalized? F: does anyone in your family has similar complain? Can you tell me about your fathers health? Can you tell me about mothers health? O: OB history Have you ever been pregnant? How many times? What was the outcome? Was the delivery normal?/ what was the mode of delivery? If CS- did you have any complain due to Sx. GYN history When was your LMP? How frequently do you have periods? Are the periods regular? (If needed) What is the duration of each period? How many pads do you have to change per day? Ask about discharge if needed When did you get your last Pap smear exam? Was the report normal?/what was report? S: Are you sexually active? Who is your sexual partner? Did you have any other partners in the last 6 months? If she says yes then ask following q. Are your partners male, female or both? Do you use any kind of contraceptive measures? Have you ever been diagnosed with STD? If yes then counseling Being sexually active with multiple partners, you are at high risk of developing STD like

gonorrhea, syphilis and HIV. The best thing you can do to avoid this diseases is to be sexually active with only one partner. At the same time you encourage your partner to have sex with you only. If you cant do this you should use condom each time you have sex. Counseling for HIV, if patient is diagnosed with STD. Since you have been diagnosed with STD like syphilis, you are at high risk of having other serious STD like HIV. As a concern physician I would like to advice you to undergo HIV testing. Although it is completely voluntary. If you want to undergo HIV testing please let me know. SA: Ask questions of smoking and alcohol Alcohol CAGE questions if needed C: have you ever tried to cut down your alcohol consumption? A: Have ever been annoyed by the criticism made by other people about your alcohol consumption? G: have you ever felt guilty about your alcohol consumption? E: Have ever needed alcohol as a first thing in the morning? Counseling for smoking: Have you ever tried to quit smoking? If yes I really appreciate that you tried to quit smoking. If no..as a concerned physician I would like to tell you that any amount of smoking is injurious to health. We have excellent smoking cessation program available in our hospital. So if you are willing to quit smoking please let me know. R: Recreational drugs Have you ever used any kind of recreational drugs? What did you use? How did you use it? If injected did you share needle with other peoples? If yes. then HIV counseling E: Exercise( counseling only if u have time) Since you are having high blood sugar/high blood pressure/ high cholesterol. It is good for you that you exercise regularly. The simplest thing you can do is jog 30 minutes, 3 times a week. If patient is exercising then say I really appreciate that you are exercising regularly. It is good for your health. D : What does your diet typically consist of? If patient is taking high fatty diet ( only if u have time) High amount of fatty food intake increases risk of certain diseases like heart problems and high blood pressure. So I would like to advice you to decrease intake of fatty food and at the same time you should eat more fruits and vegetables. If you want I can

arrange your appointment with nutrition counselor. For BP: diet counseling ( only if u have time) Since you are having high blood pressure I would like to tell you that you should eat salt restricted diet Same for high blood sugar W: what kind of work do you do? H: whom do you live with?( avoid this questions except psychiatric cases) Do you have any kind of stress at home/ work? Thank you very much for the information you gave me.

Match each of the medical terms for common symptoms in the first column with a lay term which a patient would easily understand in the second column 1. arrhythmia a) numbness 2. haematuria b) pain behind the breast bone 3. insomnia c) breathlessness 4. oedema d) complete stopping of the heart beat 5. Intermittent e) swelling or/and puffiness claudication f) needing to pass urine at night 6. dyspepsia g) heart attack 7. Ganglion h) weakness in muscles 8. Cardiac arrest i) blood in urine 9. dyspnoea j) trouble with sleeping 10. Fibromyalgia k) cramp in the leg muscles which comes 11. nocturia and goes 12. anaesthesia l) indigestion 13. retrosternal chest m) palpitations pain n) aches and pains in the muscles and 14. myocardial infarction soft tissue 15. Muscular dystrophy o) cyst on tendon sheath, usually on hand, 16. Fibrillation wrist or ankle 17. Angina pectoris p) Abnormal trembling of the heart q) Severe chest pain

EXAMINATION: While EXAMINING and discussing investigations the doctor

ought to do three things: EXPLAIN, INSTRUCT, REASSURE

Write 10 instructions against each part of the body to be examined in your Examination. For eg:the Knee---- Relax and keep your knee straight, let me give it a small tap on your knees with this little hammer Suggestions to start----you might use if you dont mind , Im just going to.. the stethoscope might feel a little cold it at any time you feel uncomfortable.. Now I would like you to .. and so on 1. The foot 2. Eyes 3.Skin 4. Hand 5. The nasal passage 6. Back 6. Abdomen (stomach) 7. Chest 8. Ear 9. Teeth 10. throat

4. Medical terms of Joint movements 1. Circumduction 2. Abduction 3. Adduction 4. Retraction 5. Pronation 6. Supination 7. Internal rotation 8. External rotation 9. Eversion 10. Inversion 11. Protraction 12. Dorsiflexion 13. Rotation 14. Plantar Flexion 15. Opposition 16. Extension

Patient Instructions

a) Lift (your arm) up b) Straighten (your knees/ elbow) c) Bend (your foot) backward d) Tilt (your head) forwards. e) Move(your feet) out f) Make small circles with g) Rotate (your hip)inwards h) Put (your arm) back down i) Move (your feet) in j) Turn (your palm) down k) Move (your hip) outwards l) Turn (your palm)up m) Tilt (your head) backwards n) Move (your head) around o) Bend (your foot) toward the ground p) Move (your thumb)away from your palm

internalexternal rotation

ABDUCTION