History and Examination
- History and Examination
- History = symptoms
- Symptoms are subjectives 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 and signs = relevant investigations request
- Symptoms + Signs + Investigations = diagnosis
Why history & examination is important?
- Reaching the diagnosis to prescribe treatment or take management decision?
- Medical reporting i. Follow-up the case ii. Medicolegal issues; Insurance companies -Police records
- Formation of summary for the case (consultation)
- To pass the clinical examination Long case scenario - Short case scenario (OSCE station)
History and Examination interpretation
- History should precede 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
History Components
- Establishing a good relationship with the patient (introduction& Permission)
- Personal Data
- Chief Complaints or presenting symptom
- History of Present Illness [HPI]
- Review of systems [ROS]
- Past medical and surgical history
- Family history
- Drug & Allergy history
- Social history
- Behavioral history
- Summery of the History
Examination Components
A. General Examination B. Systems Examinations
Challenges to perform proper history and examination
The history taking and examination performance are mainly affected by the purpose of history taking.
- The time challenge
- Avenue setting (place)
- Patient collaboration
How to overcome these obstacles ?
- Do more and more histories and examinations
- Take history in different settings.
- Write down the histories & examinations in one notebook and revise them frequently.