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INTRODUCTION TO MEDICINE
AND HISTORY TAKING
DR.NAN NITRA THAN
M.B.,B.S,DTM&H,M.C.T.M (TROPICAL MEDICINE)
LECTURER,MEDICINE UNIT,FOM
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LEARNING OBJECTIVES
• Recognise the symptoms and signs of various medical illnesses infully clothed patients
• Develop clinical acumen to recognize clinical features, including
dyspnoea, cyanosis, jaundice, pallor, general non-well being,cachexia,etc.
• Refer to the patient’s medical history and be aware of theimportance of common medical disorders in clinical dentistry,
particularly diabetes mellitus, hypertension, jaundice,epilepsy, hepatitis and other liver disorders, renal disorders, bleeingdisorders, chronic heart disease, rheumatic heart disease,
infective endocarditis,congenital heart disease,pneumonias,anaemia,
stroke, cranial nerve palsies and common tropical infections.
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MEDICINE LECTURES
Module 1 to 4 (* with tutorial classes *)
• CVS
• RS
• GIT
• Liver and biliary tract& pancreatic disorders
• Bleeding and clotting disorders• Anaemia and haemopoietic disorders
• Skeletal and joint disorders
• Connective tissue disease
• Common metabolic disorders
• Diabetes mellitus• CNS
• Peripheral nervous system disorders and neuromuscular disorders
• Skin disorders and drug induced muco cutaneous disorders
• Shock and resuscitation
• Myeloproliferative and lymphoproliferative diorders
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Clinical teaching (Clinical Skill Centre)
Module 1 to 4• CSC 1 Basic history taking in medicine
• CSC 2 Basic physical examination in medicine 1
• CSC 3 Basic physical examination in medicine 2• CSC 4 Examination of cranial nerves
V,VII,IX,XI,XII(1)
• CSC 5 Examination of cranial nervesV,VII,IX,XI,XII(2)
Hospital visits (4)
Common medical illness
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HISTORY TAKING
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INTRODUCTION
Aim:
– At the end of the session students should know fundamentals of history taking and take a history of a simple disease
Objectives:At the end of the session students should record:
– Chief complaint
– Present illness
– Past medical history
– Systemic enquiry – Family history
– Drug history
– Social history
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• Have a system based approach
• Be focused
• Practice makes you perfect
• BLISS: Beginning, Listening,
Information gathering, Sharing
information, Setting goals.
STEPS
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• Identify and Greet the patient
• Introduce yourself
• Understand the mood of the patient
• Be sensitive to the patient’s privacy and
dignity
• Make him comfortable while taking
history
GENERAL APPROACH
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COMMUNICATING WITH PATIENT
• Speak clearly and audibly
• Listen keenly with patience• Do not jargon
• Do not use medical terms
• Avoid leading and direct questions
• Do not interrupt the patient
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TAKING THE HISTORY
AND RECORDING
Always record personal details:
– Name,
– Age,
– Sex,
– Address,
– Ethnicity,
– Occupation,
– Religion,
– Marital status.
– Record date of examination
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ELEMENTS
• Presenting complaint
• History of presenting complaint
• Past medical history and risk factors
• Drug history and allergies
• Family history
• Social history
• Systemic or other system enquiry
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PRESENTING COMPLAINTS
• Main reason to push the patient seeking a physician’sconsultation
• Short/specific in one clear sentence communicating
present/major problem/issue
• Record the problem in the patient’s own words
• Mention the duration of the illness
• Arrange the complaints in a chronological order interms of duration
Note: CC should be ut in atient lan ua e E . Chest ain for one month duration
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PRESENTING COMPLAINTS IN CVS
& RS
• Chest pain (angina)
• Shortness of breath ( Dyspnoea)
• Giddiness (Syncope)• Feel the heart beat or tap (Palpitation)
• Ankle swelling (Pedal edema)
• Cough• Claudication pain
• Fatiguability
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PRESENTING COMPLAINTS IN GIT
• Abdominal pain : constant or colicky / sharp ordull/ site / radiation/duration/onset/severity/relation tofood
• Swallowing difficulty
• Indigestion
• Nausea vomitting
• Bowel habit : constipation/diarrhea
• Tenesmus or urgency
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PRESENTING COMPLAINTS IN GUT
• Incontinence• Painful micturition
• Haematuria (bloody micturation)
• Nocturia (Needing to micturate at night)
• Frequency ( frequent micturition)
• Polyuria( frequent passing of large volume of urine)
• Hesitancy (difficulty starting micturition)
• Vaginal discharge: menses, frequency,regularity, heavy or light, duration, painful or not
• Number of pregnancy
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PRESENTING COMPLAINTS IN NS
• Special senses: sight, hearing,smell and taste
• Seizures, faints
• Headaches
• Pins and needle( paraesthesia or numbness)
• Limb weakness
• Poor balance
• Speech problems
• Psychiatric problems
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HISTORY OF PRESENT ILLNESS
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• Elaborate on the chief complaint in detail
• Ask relevant associated symptoms
• Have differential diagnosis in mind• Lead the conversation and thoughts
• Decide and weight the importance of
minor complaints
HISTORY OF PRESENT ILLNESS
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• Avoid medical terminology and make use of a descriptivelanguage that is familiar to them
• Ask SOCRATES for each symptom ( Pain)
Site : somatic (sprain ankle) or viseral ( angina )
Onset: gradual or sudden
Characteristic :Sharp/dull/burning/tingling/boring/stabbing/crushing/tugging(prefer using pt’s description)
Radiation: eg. Neuronal pathway – diaghragmatic pain at theshoulder tip via the phrenic nerve
Associated symptoms(nausea , sweating)Timing: of pain / duration
Exacerbating & relieving factors :(food/activity/posture/medication)
Severity : difficult to access . May be with scale of 1 to 10
HISTORY OF PRESENT ILLNESS
Hi f P i C l i (HPC)
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Sequential presentation
•Always relay story in days before admission e.g. 1 week before the
admission, the patient fell while gardening and cut his foot with a stone.
•Narrate in details – By that evening, the foot became swollen and patient
was unable to walk. Next day patient attended hospital and they gave
him some oral antibiotics. He doesn’t know the name. There is no effect
on his condition and two days prior to admission, the foot continued toswell and started to discharge pus. There is high fever and rigors with
nausea and vomiting.
History of Presenting Complaint(HPC)
In details of symptomatic presentation
•If patient has more than one symptom, like chest pain, swollen legs
and vomiting, take each symptom individually and follow it throughfully mentioning significant negatives as well. E.g the pain was central
crushing pain radiating to left jaw while mowing the lawn. It lasted for
less than 5 minutes and was relieved by taking rest. No associated
symptoms with pain/never had this pain before/no relation with food/he
is Known smoker,diabetic & father died of heart attack at age of 45.
In details of present problem with- time of onset/ mode of evolution/ any
investigation;treatment &outcome/any associated +’ve or -’ve symptoms.
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PAST MEDICAL HISTORY
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• Start by asking the patient if they have any medicalproblems
• IHD/Heart Attack/DM/Asthma/HT/RHD,TB/Jaundice/Fits :E.g. if diabetic- mention time of diagnosis/current medication/clinic check up
• Past surgical/operation history
• E.g. time/place/ and what type of operation. Note anyblood transfusion and blood grouping.
• History of trauma/accidents
• E.g. time/place/ and what type of accident
Past medical history
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DRUG HISTORY
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Drug History
• Always use generic name or put trade
name in brackets with dosage, timing and
how long. Example: Ranitidine 150 mgBD PO
• Note: do not forget to mention
OCP/Vitamins/Traditional medicine
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FAMILY HISTORY
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• Any familial disease/running in families
e.g. breast cancer, IHD, DM,schizophrenia, Developmental delay,
asthma, albinism
FAMILY HISTORY
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SOCIAL HISTORY
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SOCIAL HISTORY
• Smoking history - amount, duration and type.
A strong risk factor for IHD
• Drinking history - amount, duration and type.
Cause cardiomyopathy, vasodilatation
• Occupation, social and education background,
family social support and financial situation
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OTHER RELEVANT HISTORY
• Gyane/Obstetric history if female
• Immunization if small child
• Note: Look for the child health card• Travel and sexual history if suspected STI or infectious
disease• Note:
• If small child, obtain the history from the care giver.Make sure; talk to right care giver.
• If some one does not talk to your language, get aninterpreter(neutral not family friend or member alsofamiliar with both language). Ask simple & straightquestion but do not go for yes or no answer.
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System Review (SR)This is a guide not to miss anything
Any significant finding should be moved to HPC or PMH
depending upon where you think it belongs
Do not forget to ask associated symptoms of PC with theSystem involved
When giving verbal reports, say no significant finding on
systems review to show you did it. However whenwriting up patient notes, you should record the systems
review so that the relieving doctors know what system
you covered
System Review
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System Review
Respiratory System
•Cough(productive/dry)
•Sputum (colour, amount,smell)
•Haemoptysis
•Chest pain•SOB/Dyspnoea
•Tachypnoea
•Hoarseness•Wheezing
Cardiovascular•Chest pain•Paroxysmal Nocturnal Dyspnoea
•Orthopnoea•Short Of Breath(SOB)•Cough/sputum (pinkish/frank blood)
•Swelling of ankle(SOA)
•Palpitations•Cyanosis
Gastrointestinal/Alimentary•Appetite (anorexia/weight change)•Diet
•Nausea/vomiting
•Regurgitation/heart burn/flatulence•Difficulty in swallowing
•Abdominal pain/distension
•Change of bowel habit•Haematemesis, melaena,haematochagia
•Jaundice
General•Weakness
•Fatigue
•Anorexia
•Change of weight
•Fever
•Lumps•Night sweats
S t R i
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System Review
Urinary System•Frequency
•Dysuria
•Urgency
•Hesitancy
•Terminal dribbling
•Nocturia
•Back/loin pain•
Incontinence•Character of urine:color/ amount (polyuria) & timing
•Fever
Nervous System•Visual/Smell/Taste/Hearing/Speechproblem
•Head ache
•Fits/Faints/Black outs/loss ofconsciousness(LOC)
•Muscleweakness/numbness/paralysis•
Abnormal sensation•Tremor
•Change of behaviour or psyche
Genital system
•Pain/ discomfort/ itching
•Discharge•Unusual bleeding•Sexual history
•Menstrual history – menarche/ LMP/ duration & amount of cycle/ Contraception
•Obstetric history – Para/
Musculoskeletal System•Pain – muscle, bone, joint
•Swelling
•Weakness/movement•Deformities
•Gait
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Conclusion (SOAP)Subjective: how patient feels/thinks about him. How does
he look. Includes PC and general appearance/condition of patient
Objective – relevant points of patient complaints/vital
sings, physical examination/daily weight, fluid balance,
diet/laboratory investigation and interpretation
Plan – about management, treatment, further
investigation, follow up and rehabilitation
Assessment – address each active problem after making a
problem list. Make differential diagnosis.