BYGeorges Metellus, M.D., M.P.H

The history is the single most important tool in obtaining a diagnosis. It is an extraordinary investigative technique.

History taking requires a clinician-patient inter action and therefore, a connection between the two is important for the objectivity of the process. Your attitude of friendliness and obvious respect will go a long way in the pursuit of information and ensuring your patient’s help in obtaining.

Patient-Doctor connection: This can be achieved through:

A. Active listening: 1. Choose a mutually comfortable setting (including

taking into consideration the patient’s circumstances) 2. Remain quiet and attentive 3. Avoid interrupting unless you really have to. 4. Do not anticipate the next question before you have

heard the complete answer. 5. A good history requires that the doctor be aware of

and be sensitive to cultural differences. 6. Strive to remove your own beliefs, prejudices, and

preconceptions from observations. 7. Communication: verbal an non-verbal (body

language) 8. Avoid sophisticated medical jargon.

Patient-Doctor Connection (cont”) B. Accuracy and reliability of information: 1. Information obtained must be sufficiently detailed and

unambiguous to use in diagnosis and treatment. 2. Avoid leading Questions 3. In case of doubt, clarify by asking questions such as “what do

you mean?” 4. Be reassuring: involves making an educated guess regarding

what the patient is likely to be worried about and dealing specifically with those worries.

5. Be careful when dealing with moments of tension generated by anxiety feeling, depression, crying, dementia…

7. Be aware of manipulation, seduction, anger, alcoholism, sexual uncertainties.

The structure Include: 1. Identifying Information: date, time, age, sex

race, occupation, and referral source. 2. Chief complaint (CC): is a brief statement of

the reason the patient is seeking health care. Directly quoting the patient is helpful. It may include the duration of the problem.

3. History of Present Illness (HPI): is a thorough elaboration of the chief complaint and other current symptoms starting from the time the patient last felt well until the present. State of health just before the onset of the present problem. Exacerbation and relieving factors. History of exposure to infection or toxic agents. Medication. Stability of the problem. Impact on the patient’s usual life style.

4. Past Medical History (PMH): Childhood illness: Measles, mumps, whooping

cough, chicken pox, smallpox. Scarlet fever… Major adult illnesses Immunizations Surgery Serious injuries Medications Allergies Transfusion Hospitalization Emotional status

5. Family History (FM): Ask if there are any blood relatives in the

patient’s family who have illnesses with features similar to the patient’s illness.

Determine the ethnicity; health; and, if applicable, the cause of death of parents and siblings, including their age of death

Establish whether there is a history of heart disease, high blood pressure, cancer, TB, stroke, epilepsy, diabetes, gout, kidney disease, thyroid disease, asthma and other allergic states, forms of arthritis,blood disease, STDs…

Determine the age and health of the spouse’s parents and children

7. Personal and Social History (SH) Personal status: Birth Place, home

environment, socioeconomic class, cultural background, education, marital status, general life satisfaction, source of stress…

Habit: Nutrition and diet; regularity and patterns of eating and sleep; exercise; ; coffee, tea, tobacco , alcohol, use of recreational drugs (frequency, type). Breast or testicular self-examination, sexual history, home conditions, occupation, environment, military record, cultural requirement…

Review of System (ROS) A few questions about each major body

system ensures that problems will not be overlooked.

The physician should avoid the mechanical “rapid fire” questioning technique that discourage patients from answering truthfully because of fear of ‘annoying the doctor”

The Physical examination begins as one is taking the history, by observing the patient and beginning to consider a differential diagnosis.

1.General appearance: Patient’s body habitus State of grooming Nutritional status Level of anxiety Degree of pain or comfort, mental status, speech pattern and use of language

Are considered the baseline indicators of a patient’s health status. They may be measured early in the physical examination.

Pulse Respiration Blood Pressure Temperature Measurement of height and weight

The pulse may provide information about the rate, strength, and rhythm of the heartbeat.

The pulse may be palpated in several different areas. The nine major “pulse points” are named after the arteries over which they are felt.

To feel a pulse, you must place the pads of your second and third fingers over an artery that lies near the surface of the body and over a bone or a firm base.

1. Over the superficial temporal artery in front of the ear. 2. The common carotid artery in the neck along the front

edge of the sternocleidomastoid muscle. 3. Over the facial artery at the lower margin of the

mandible at a point below the corner of the mouth. 4. In the axilla over the axillary artery 5. Over the brachial artery at the bend of the elbow along

the inner or medial margin of the biceps brachial muscle 6. At the radial artery at the wrist (radial pulse). It is the

most frequently monitored and easily accessible in the body

7. Over the femoral artery in the groin. 8. At the popliteal artery behind and just proximal to the

knee 9. At the dorsalis pedis artery on the front surface of the

foot, just below the bend of the ankle joint

TYPE/DESCRIPTIONASSOCIATED CONDITIONS

Pulsus alternans: regular rate; amplitude varies from beat to beat alternating weak and strong beats

Bigeminal pulse: Two beats in rapid succession (one normal, one premature) followed by longer interval; easily confused with alternating pulse.

Pulsus bisferiens: Two strong systolic peaks separated by a midsystolic dip.

Left ventricular failure

Regularly occurring ventricular premature beats

Aortic regurgitation alone or with stenosis

TYPE/DESCRIPTION ASSOCIATED CONDITION

Bounding pulse: increase pulse pressure; contour may have rapid rise, brief peak, rapid fall (hyperkinetic pulse).

Bradycardia: rate <60

Artherosclerosis, aortic rigidity, patent ductus arteriosus, fever, anemia, hyperthyroidism, anxiety, exercise

Hypothermia, Hypothyroidism, drug intoxication, impaired cardiac conduction, exellent physical conditioning

TYPE/DESCRIPTIONASSOCIATED CONDITIONS

Paradoxic pulse: Amplitude decreases (>10mmHg)on inspiration and increases on expiration

Pulsus differens: Unequal pulses between left and right extremities

Tachycardia: Rate over 100

Chronic obstructive disease, constrictive pericarditis, pericardial effusion

Impaired circulation, usually from unilateral local obstruction

Fever, hyperthydoidism, anemia, shock, Heart disease, anxiety, exercise

TYPE/DESCRIPTIONASSOCIATED CONDITIONS

Trigeminal pulse: three beats followed by a pause.

Water-hammer pulse (Corrigan pulse): Jerky pulse with full expansion followed by sudden collapse

Often benign, such as after exercise; but may occur with cardiomyopathy, severe ventricular hypertrophy, severe aortic stenosis, dysfunctional right ventricle.

Aortic regurgitation

Blood pressure is the pressure or “push” of blood as it flows through the circulatory system. It is a peripheral measurement of cardiovascular function.

Indirect measures of blood pressure are made with a stethoscope and a sphygmomanometer (aneroid or mercury) or with electronic sphygmomanometers which do not require the use of a stethoscope

Blood Volume The strength of each heart contraction Heart rate The thickness of blood (viscosity) Rigidity of the arteries

The larger the volume of blood in the arteries, the more pressure the blood exerts on the walls of the arteries.

The less blood in the arteries, the lower the blood pressure tends to be. (Hemorrhage demonstrates this relation between blood volume and blood pressure)

A stronger heartbeat increases blood pressure and a weaker beat decreases it.

Cardiac output is also influenced by the strength of the contraction of the heart

The rate of the heart also affects arterial Blood pressure. When the heart beats faster, more blood enters the aorta, therefore the arterial blood volume and blood pressure would increase.

The stroke volume is to be considered because it might determine whether or not the blood pressure is going to change in one way or another

If blood becomes less viscous than normal, blood pressure decreases. (if a person suffers a hemorrhage, fluid moves into the blood from the interstitial fluid. This dilutes the blood and decreases its viscosity, and blood pressure)

In a condition called Polycythemia, the number of red blood cells increases beyond normal and thus increases blood viscosity. This in turn increases blood pressure.

Increased arteriolar resistance is the most common cause of hypertension. This increase may occur secondarily to:

1. Endocrine causes: Tumor of the adrenal medulla

( Pheochromocytomas) produces epinephrine and norepinerphrine and may give rise to paroxysmal form of hypertension

2. Renal Causes:

2. Renal Causes

a) Renal parenchyma: Chronic glomerulonephritis Pielonenephritis Polycystic disease b) Renal vasculature vascular lesions due to congenital or acquired malformation of the renal artery or to small vessels disease as such in lupus erythematosus. 3. Essential Hypertension: is the most common cause of a pathologically elevated blood pressure. The disease shows a marked familial tendency, and it appears commonly in middle-aged people. It is one of the most common causes of left ventricular Hypertrophy.

Hypotension results from: 1. Decrease of cardiac output: In Addison’s disease, myocarditis, myocardial infarction,

pericarditis with effusion, and following hemorrhage

2. Decrease in peripheral resistance Vasomotor collapse, may occur in: Pneumonia Septicemia Acute Adrenal insufficiency (Waterhouse-Frederichsen

syndrome) Drug intoxication( a sudden drop in blood pressure should be regarded as a

grave sign)

Respiration means exchange of gases( oxygen and carbon dioxide) between a living organism and its environment

Respirations are counted and evaluated by inspection. Observe the rise and the fall of the patient’s chest and the ease with which breathing is accomplished. Count the number of respiratory cycles (inspiration and expiration) per minute.

Observe the regularity and rhythm of the breathing pattern.

Note the depth of respirations and whether the patient uses accessory muscles.

Tachypnea: Is a persistent respiratory rate approaching 25 respirations per minute. Certain patients with fibrosis of the lung, pulmonary edema, pleural disease, or rib cage fixation may breathe rapidly and shallowly. Other patients may increase the minute ventilation to accommodate an increased gas exchange that is necessitated by exercise, fever, hypermetabolic states, or anxiety

Bradypnea: rate slower than 12 respiration per minute. May indicate neurologic ( i.e intracraneal pressure: hemorrhage, tumor) or electrolyte disturbance, infection or a sensible response to protect against the pain of pleurisy or other irritative phenomena (it may also mean splendid level of cardiorespiratory fitness)

Kussmaul Respiration: deep, rapid and labored respiration associated with metabolic acidosis. May indicate decompensated diabetes with profund acidosis; renal diseases or drug causing acidosis. Diseases of the central nervous system, such as meningitis, may increase minute ventilation

Cheyne-Stokes respiration: A regular periodic pattern of breathing, with intervals of apnea followed by a crescendo/decrescendo sequence of respiration. It occurs in patients who are seriously ill, particularly those with brain damage at the cerebral level or with drug-caused respiratory compromise.

Biot Respiration: Consists of somewhat irregular respirations varying in depth and interrupted by intervals of apnea. It is usually associated with severe and persistent increase intracranial pressure, respiratory compromise resulting from drug poisoning, or brain damage at the level of the medulla.

The assessment of body temperature may often provide an important clue to the severity of a patient’s illness. Temperature measurement can be accomplished through several different routes, most commonly:

oral, rectal, axillary, tympanic membrane (less common) In the case of bacterial infection it may well be

the most critical diagnostic indicator, especially with infants, toddlers, and the elderly

Important conditions related to body temperature:

1. Fever: Is an unsually high body temperature associated with a systemic inflamatory response. In the case of infections, chemical called Pyrogens cause the thermostatic control centers of the hypothalamus to produce fever.

2. Malignant hyperthermia: Is an inherited condition characterized by an abnormally increased body temperature and muscle rigidity when exposed to certain anesthestics

4. Heat exhaustion: Occurs when the body loses a large amount of fluid resulting from heat-loss mechanism. This usually happens when environmental temperatures are high. The loss of water and electrolytes can cause weakness, vertigo, nausea, heat cramps and possibly loss of consciousness

Heatstroke or sunstroke: is a severe condition resulting from the inability of the body to maintain a normal temperature in an extremely warm environment. Such thermoregulatory failure may result from factors such as old age, disease, drugs that impair thermoregulation, or simply overwhelming elevated environmental temperatures.

Hypothermia: is the inability to maintain a normal body temperature in extremely cold environments. Hypothermia is characterized by body temperature lower than 35C (95F), shallow and slow respirations, and a faint, slow pulse.

Frostbite: is local damage to tissues caused by extremely low temperatures. Necrosis and even gangrene can result from frostbite.

Procedures for accurately measuring height, weight, and triceps skinfold. These measures are useful in assessing a patient ‘s nutritional status and possible disease risk.

Body Mass Index: is a formula used to assess nutritional status and total body fat. It is a measure of Kg per meter squared. For adult men and women, a BMI between 18.5 and 24.9 is expected

Mid-Upper Arm Circumference: provides a rough estimate of muscle mass and available fat and protein store.

Obesity: Exogenous Obesity: there is an increase in the

number of fat cells, as much as 3 to 5 times normal (excess fat tissue is generally located in the breasts, buttocks, and thighs and is associated with excessive calorie intake.

Endogenous obesity: The fat cells are greatly enlarged. Excess fat tissue is distributed to certain regions of the body, such as the trunk, or abdomonal area. Men are more likely to have this type of obesity and is associated with higher risk of diabetes, heart disease, high blood pressure, and stroke.

Anorexia Nervosa Emotional disorder occurring most commonly in adolescent

females, characterized by abnormal body image, fear of obesity, and prolonged refusal to eat, leading to emaciation, amenorrhea, and other symptoms, and sometimes resulting in death.

Bulimia: Potentially serious disorder, especially common in adolescents

and young women, marked by insatiable craving for food and leading to episodes of excessive overeating, often followed by self induced vomiting, purging, or fasting

Anemia Condition in which the hemoglobin content of the blood is below

normal limits.

Hyperlipidemia: Disorders resulting in higher than normal level of lipids in the

blood

AndGOOD LUCK!