Introduction to Medical History & Clinical Examination
Dr Sami Fatehi MBBS, MSc, MD, PhD
History & Examination
- History = symptoms
- Symptoms are subjective information delivered by the patient so need more clarifying
- Examination = signs
- Signs are objectives information obtained by clinician need assistant tools, instruments and maneuvers
- Symptoms and signs should be consistent and if not, recheck
- Symptoms + Signs = differential diagnoses
- Symptoms + Signs + Investigations = diagnosis
Why history & examination is important?
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To reach diagnosis in order to prescribe treatment or take management decision?
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To construct a medical report i. Follow-up the case ii. Medicolegal issues
- Insurance companies
- Police records
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Formation of summary for the case (consultation)
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To pass the clinical examination
- Long case scenario
- Short case scenario (OSCE station)
Relation between history and examination
- History directs the examination focusing
- History should be consistent with examination findings
- If they are not consistent you have to take history and repeat examination and try to find explanation