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History Taking & Examination

Sep 18, 202411 min read

Method 1 Hx & Exam

Personal framework built by instructors within clinic for quick follow through other than what devised by university - the history taking and examination through series of steps to optimize the needed information for differential diagnosis, investigation methods, and treatment from simple charting method

Initial clinical charting method

Chief Complaint ⇒ Associated Symptoms ⇒ Differential Diagnosis

THx/RO + IE/RO + CMS

History Taking & Examination

Write the following as base table to history taking from patient directly first of all ask patient what is his complaint and let him talk, then ask specific questions to every symptoms for more information.

Note the vital sign founded in patient charts, their chief of complaint, age, sex. build upon them the differential diagnosis prior to entering to the patient.

45 male sudanese

Chief of complaint= SOB Vitals if there is one= temperature 37c, bp 180/100, pulse; 130 Diff = Asthma, Bronchiectasis, Allergic reaction, pericarditis, HF, IHD, stroke most of which would be eliminated after initial investigations Upon Diff you can build upon questions that can be asked to be rule out History taking, examination, inspection, investigations, treatment.

  • THx + R/O (Onset/Symptoms) + (Rule out + systemic review/associated symptomps)
  • IE + R/O (On Inspection/Examination) + (Rule out)
  • CMS (Comorbidities/Family history, Medications/allergiens, same episode, Surgeries, transfusions Occupational, Social, Risk factors)
THx/ROIE/ROCMS
2D SOBpatient is orientated and alert GSC 15/15DM +hx
3D Progressing constant Chest PainClubbing, Peripheral CyanosisHTN -hx
4D ConstipationSystolic MurmurSplenectomy 2y
2M ArthlagiaVisible PalpatationSmoker 1y 1packw
No vomittingUnilateral radiation pain to arm, shoulderConstruction worker
No dizinessNo Neurological findings
No diarrheaNo gastrointestinal Tenderness / Soft lax
No FeverVesicular Lung Sounds

Diff Reduced= HF, IHD, Pericarditis, PE - noting needed investigations Initial Investigation= X-ray, ECG, Troponin I, CBC, CK-MB etc… based upon reduced diff Supplementary Treatment= Analgesics, Diuretics, BP maintenance… Effective Treatment= Diagnosis reached for directive effective treatment

Other Simplified

Five Parts

  1. Analysis ⇒ Id chief
  2. Associated symptoms
  3. B- symptoms malignancy
  4. Past Hx
  5. Systemic Review

OR

Four parts

  • History
  • Clinical exam
  • Summary & Differential diagnosis
  • Investigations & Management

dont be biased in examination

Examples of Presentation EX: 77 years old male sudanese he came to ER complaining of chest pain for 9 days, diffused tightness gradual tightness exacberating by exertion, relieving by rest, associated with cough with clear phlegm, severe sob 1-2h before presentation to ER- no palpitation, no syncopal attack, no b symptoms

diffused gradual chest pain

EX: headache for 3 days - - associated with photophobia constant for 3 hours before presentation - also theres hx of numbness with no seizure, no neck stiffness

Framework presentation: A/S/C presented to … complaining of … for 5D (Socrates/Operates) associated with (same system + Detail) + Exclusion

Method 2 Hx & Exam

1) Demographic

Name, age, Martial status, Nationality, Residency,
(Occupation also can be said in social history)

EX: 54 year old male driver, not married, lives in apartment in riyadh

2) Chief of complaint

why did you come to hospital; write same as “Abdominal pain ((not specific to Epigastric pain))

3) HPI

  • HPI features⇒
  • associated symptoms + days + detail, then with exclusion + leg swelling
  • B symptoms; weight loss, loss of apetite, fever, night sweats
  • then lastly systemic review (could be after past hx)

Complaining of 5 day hx of progressive diffused abdominal pain relieved by sitting, exacerbated by movement associated with… no reported b symptoms… no other system findings…

in depth Systemic review always yes or no question - direct questions
CNS Sys

  • ICP; Symptomps
  • Motor weakness
  • Sensory; parathesia in DM, hemiparesis
  • CNV; ask on all cranial nerve symptoms
  • Cerebellar; Abnormal movement
  • Sphincter; Bladder - autonomic; DM CNS

Cardiac Sys

  • Ischemic; Retrosternal pain, Stabbing/Heaving, Radiation proximity, increased with exertion, relieved with glycerine; coronary heart disease; MI, Angina etc…
  • Non-Ischemic; Diffused chest pain, increased with cough, strain, breathing; skin infection neuralgia, muscle myopathy, rib fracture/truama costrochondritis, pleural effusion, parynchemous lung, Pulmonary Embolism, SOB
  • Grade of dyspnea I-IV; association w/ orthopnea? pillow? wake up w/ SOB? ; paroxysmal
  • CVS cause dyspnea; pericarditis, myocardial infarction, valvular heart disease
  • RESP cause dyspnea; pneumonia, TB, initial lung fibrosis, cough, Hemoptysis, use of accessory muscles

Resp Sys

  • Productive; Phelgm / Nonproductive;Dry - amount, Color, Smell
  • Asthma, COPD, Bronchiestasis,
  • hemoptysis; resp | Hematemesis; git - frequency, clotting
  • bleeding tendency, severe mitral stenosis

GIT Sys
Upper: Heart burn, neusea, vomitting, abdominal pain, dysphagia

  • Dysphagia; timing of swallow - oropharyngeal vs esophageal | liquid or solid on dysphagia | Continuous or interrupted | Presentation of: scleroderma, malignancy, Infection, Neusea, vomitting, heart burn, epigastric pain; left
    - Pain Radiation
    Heaving/ Colicky pain: ?
    Radiation epigastric to right shoulder: cholecystitis
    Epigastric to back: Pancreatitis
    Relieved by leaning forward: pericarditis
    - Melena; dark stool if upper GIT blood
    - Renal Symptoms: Pyelonephritis, renal stone w/ fever, bone ache, lost of apetite ||| lower with frequency/urgency/like tea?
    Lower: ??? CC

itching; obstructive jaundice,
urine, stool, vomitting, loss of weight, job, iv, sexual, fever
autimmune = thallassemia, hemolytic anemia
infectious= malaria

paracetamol liver toxicity - 5 times per day

old age; pancreatic cancer

Gym; anabolic steroid - cholecstsyic jaundice

MSK

  • Joint pain;

    • Arthritis; redness, Hotness, swelling, tenderness, limited motility
    • Arthralgia;

  • Mechanical vs Inflammatory

    • Mechanical; Traumatic - constant bone ache, increased with activity
    • Inflammatory; morning stiffness improving with activity

  • Type of Joint
    small joint of hand -
    Large joint -

  • Symmetry

  • Associated Rheuma Symptomps
    Autoimmune, SLE, Rheumatoid Arthritis, Lupus

4) Past HX

past medical:

  • similar episode as before - (you can mention with HPI)
  • Chronic diseases + Family Hx / similar conditions
  • Past Admission + transfusion + Surgeries
  • Pregnancy / Lactation
  • Medication (name dose side effects)
  • Allergy

Social: im going to ask some specific question to reach to diagnosis, may i?

  • Occupation, Travel, kids, smoking, alcohol, drugs, sexual activity

5) Summary

77 yo sudanese male complaining of chest pain for 9 days which was severe compressing radiating to back associated with cough, with no hx of palpitation, syncopal attack - with hx of cabg.

6) Differential, Impression

put three differential for example;

  • autoimmune,
  • malignancy,
  • infection

7) Workup / Investigation

routine; Blood sugar, electrolyte, CBC
Related to System - Spirometry, Bronchoscopy, MRI, CT etc… ANA antibody sle, specific tests - ANTI-TPO; Thyroid

B- Examination

Remember Wiper

  • W ash hands (before and after)

  • I ntroduce yourself to the patient and seek his or her consent

  • P osition the patient correctly.

  • E xpose the patient as needed (e.g. ‘Please take off your shirt for me now, if that is all right’)

  • R ight side of the bed

  • Exposure | position | privacy (important to mention in every exam process)

1- General Appearance

  • Conscious and alert
  • features
  • connected devices

Summary for general Appearance
EX: elderly male with good build lying comfortable to be - connected to cannula - not connected oxygen. (note general exam findings)

EX: young boy morbidly obese, in resp distress connected to oxygen

2- General examination: ask for Vitals - CHECK Leg swelling
dont touch patient until needed

  • Hand: organized explaination from distal to proximal

    • distal - nail, feature…
    • no janeway.. no osler node…
    • specific - cardiac, GIT, Resp
    • no infection, no swelling, no deformitiy in dorsum
    • no palmar erythema: liver cirrhosis, mitral stenosis , rheumatoid arthritis
    • No janeway lesion: CVS
    • Leukonechia kolionechia
    • Clubbing (window test); Hypoxia; angiogenesis many causes— likely resp cvs, congenital heart diseases, malignancy
    • Rheumatoid deformity w/ ulnar deviation - Z shape thumb, fixed not correctable - ((swan neck vs boutonniere??)), guttering.
    • Sweaty; Hyper
    • Thick: Depature contracutre???, hypothyroidism
    • Dry: hypo

  • Clubbing - window test

  • Capillary refill

  • Pulse: (rate | rhythm | character | volume | comparison | radioradial delay)

    • Dorsalis pedis
    • Medial Malleolus
    • Popliteal arteria

  • water hammer pulse

  • Vital signs - BP, RR, Temp, Pulse, saturation, - mention need to check

  • Face & Neck: head to neck

    • general appearance
    • Hair: normal hair distribution
    • eye: no pallor/jaundice
    • Nasal: no nasal discharge
    • Mouth: oral hygiene, central cynosis, oral ulcers
    • Neck: no obvious thyroid LN JVP, cyst, swallow - want me to examine?

  • Abdomen: general palpation -

  • Lower Limb: Edema - thumb
    Edema Grading

    • GRADE I: edema from dorsum of foot & then behind medial malleolus bilateral;
    • GRADE II: Tibial
    • GRADE III: Pinching, catching fold of skin on thigh to check edema
    • GRADE IV: Antero-Abdominal wall; peduea orange appearance, thick, red +++ Sacral edema; ascites ((generalized anasarca?))

3- Specific system exam
… revise https://medatlax.com/Clinical/Level-8/Clinical-Medicine/Clinical-Medicine - inspection, palpation, auscultation, percussion 4- thank patient, then document it

5- Summary
old age gentlemen comfortable in bed not in resp distress positive
central cynosis, decrease air entry on right side, lower limb edema

Other notes?

  • Giddiness; sense of blackout when standing up

  • Extrasystole? - af? - irregular ireggularities>

  • leg swelling; edema, SOB; dyspnea

  • smell sputum abcess foul, productive

  • Severe mitral stenosis might present with hemoptysis

  • Aortic Regurge collapsing pulse/ nodding sign

    • anemia, paggets disease, pregnancy, thyrotoxicos
    • av shunt

  • MCV type of anemia?

  • Platelet count thrombocytopenia; skin rash bleeding tendency

  • ITP, Heparin induced, SLE, Von wil dis, TTP

  • check edema

  • Grades of edema

  • causes of unilateral

  • causes of bilateral: renal, liver, heart…

  • infection, malignancy, autoimmune

  • ROutine Labs - signs each cbc

Method 3 Hx & Exam

extensive method of History Taking framework from textbooks — Case presentation -

I- Demographic:

  • Name:
  • Age:
  • Nationality:
  • Martial Status:
  • Residency:
  • Occupation:

II- Chief of complaint

Main Patient answer why he is on admission:

III- History of Present Illness - HPI

on each symptom follow through these method SOCRATES:

OPERATES:

Associated Symptoms to same system:

IV- Past History

  • Medical:
  • Family:
  • Surgical:
  • Medications
  • Allergens:
  • Social History:

V- Systemic Review

  • Malignancy:
  • CNS:
  • RESP:
  • CVS:
  • GIT
  • Urogenital:
  • MSK:
  • Endocrine:
  • Hematological & Immunological:
  • Psychiatric:

C- VI- Physical Examination

  • Vital Signs:

  • General Appearance:

  • Involved System:
  • System-by-System Exam:

VII- Assessment

  • Problem List:
  • Differential Diagnosis:

VIII- Plan

  • Diagnostic:
  • Therapeutic:

SUMMARY:

In Depth Explanation

1. History

  • Chief Complaint: Clearly state why the patient is seeking medical attention (e.g., “chest pain for the last week”).
  • History of Present Illness (HPI): Detail the patient’s current problem, including:
    • Onset (when it started, suddenly or gradually)
    • Location (where the problem is)
    • Duration (how long it lasts)
    • Character (what it feels like - sharp, dull, etc.)
    • Aggravating/Alleviating Factors (what makes it worse/better)
    • Radiation (does it spread)
    • Associated symptoms
    • Previous treatments and their effectiveness
  • Past Medical History: List significant past medical conditions, surgeries, hospitalizations, and medications.
  • Social History: Document lifestyle factors like alcohol use, tobacco use, and occupation.
  • Family History: Note any relevant family history of medical conditions.
  • Review of Systems: Inquire about symptoms related to different body systems (e.g., cardiovascular, respiratory, etc.).

2. Physical Examination

  • Vital Signs: Record temperature, pulse, respiration rate, and blood pressure.
  • General Appearance: Note the patient’s overall appearance (e.g., alert, distressed).
  • System-by-System Exam: Document findings for each body system (e.g., skin, HEENT, cardiovascular, etc.). Be specific and note both normal and abnormal findings.

3. Assessment

  • Problem List: Create a list of the patient’s active medical problems.
  • Differential Diagnosis: For each major problem, consider possible diagnoses and explain why you favor one over others, citing evidence from the history and physical exam.

4. Plan

  • Diagnostic: Outline any further investigations needed (e.g., blood tests, imaging).
  • Therapeutic: Detail treatment plans, including medications, procedures, and lifestyle modifications.

Other Information

Note

  1. wash hands, take permission, inspect
  2. I will proceed to palpation; ask permission see the patient eye

2 Session - each 5 minute Hx & Examination

others…

General Exam

Ptosis

  • unilateral - horners
  • bilateral - mysthenia gravis
  • 3rd nerve palsy
  • ((double aortic los??))

How to know Horner or nerve palsy? Mydriasis suggests Horner’s syndrome

Eye

  • Subconjatival hemorrhage causes (HTN-hemophilia)
  • Conjunctiva cyanosis called central cyanosis

Face

  • Facial flushing (Mitral stenosis)
  • Buffy face (Renal Failure)

conjunctival hemorrhage due

  • HTN
  • Subacute endocarditis

mouth

  • Angular stomatitis (iron defec - V B12 - allergy)
  • Ulcers, Central cyanosis, oral hygiene \

Hand Osteoarthritis 2 signs : •

  • Heberden nodes: pain and nodular thickening on the dorsal sides of the distal interphalangeal joints, ♀ > ♂

  • Bouchard nodes: pain and nodular thickening on the dorsal sides of the proximal interphalangeal joints ,

Neck Palpate neck if there’s nothing just don’t say anything - Check JVP: not rised at 45•

Hepatojauglar reflex in normal waves will be disappearing while relase hand while HF will be sustained

Aortic stenosis may radiate to the whole pericrod

notes hepatojugular reflux 30-60 seconds - sustained = ?

Examination General Exam - atleast 5 minutes (ask to expose the patient to say findings)

  • First thing inspection without touching patient; Conscious, orientated, not in distressed or respiratory distress, connected to (IV line/canulla, nasal, oxygen, face mask, ECG, foley catheter, chest tube intercostal tube, pig tail, ascites drain, fistula/dialysis line, pacemaker, neubilizer machine (contained fluid), ventilator, bypab mask (non invasive ventilation - heavy mask full closure)???CC, ).

  • Vitals signs (Temp, Pulse, BP, RR (not in distress), Oxygen saturation)

  • Signs:

  • Upper limb: (comment most important signs, not everything) Clubbing causes - cardiac;, Subacute infected endocarditis’s, Cyonitic heart disease - pulmonary; interstitial lung disease, lung cancer (All clubbing; Non-small cancer; Squamous CC; smoking + Cavitation + Central + clubbing , Adenocarcinoma; periphery , Large cell carcinoma) (Small cell cancer; smoking, no clubbing) - GI: liver cirrhosis, IBD - congenital causes: ---

tar staining, peripheral cynosis, palmar erythema;

in resp COPD hyperkypnia high co2 edema (flapping tremor, same as liver cirrhosis ++ Palmar erythema ) ,

fine tremors (ventolin - beta agonist)

no HF, COPD, small cell carcinoma for clubbing idiopathic pulmonary fibrosis with clubbing lung cavity; abcess - mesothelioma - ???

  • Face & Neck: jaundice, pallor, central cyanosis, JVP, visible swelling,

  • Lower limb: Edema - pitting or non pitting, unilateral, bilateral

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