HISTORYObjective to address a provisional diagnosis

Diagnosis stands for

History Exam Investigation

HISTORY : An analysis of primary information to understand the ongoing pathology in a sequential order & this is

Medicine – A problem solving activity, An academic exercise towards solution Through brain storming.

CONTENTS OF HISTORY1) Introduction2) P/C3) HOPI4) Past history5) Treatment history6) Personal7) Family8) Social economic history

Introduction means to know about Name- Age -

Residence Occupation

PRESENTING COMPLAINT

Access throughOpen enquiryClosed enquiryClosed enquiry stands for three issuesA. ClarificationB. ReflectionC. Summary

Aims & objectives of P/C1. To keep history in flow2. To indentify issues which needs further

elaboration 3. Should be able to put a symptom (chief

complaint) into a certain system.4. Therefore to plug the right complaint with

reference to a system is the main objective.

Symptoms of GITPatient has a habit to give a diagnosis in very beginning or use vague terms, like in digestion, hyperacidity, flatulence etc, so needs to be discouraged. Symptoms are so many like ----------

HISTORY OF PRESENTING ILLNESSExtremely important part of history. Here a

medical student is judged for 1. Communication skill 2. About the depth of knowledge i.e core

knowledge 3. About the breadth of his knowledge i.e his

vision about the problem- D/D ---------4. Medical Students has been Judged for his

ability to address a logical conclusion/provisional diagnosis of presenting complaint.

A brief review of past history like known patient of CLD, Known patient of APD, known patient of IBD, etc can be pasted before the HOPI.

An important clue to understand the ongoing problem.

Most of the time the patients presenting complaint has been related with his known illness.

OPENING SENTENCE OF HOPI

Is about initial status of patient that how long he was absolutely all right or

in usual state of health ------------

FORMAT OF HOPI1. Symptom evaluation and its associations2. Working diagnosis 3. Differential diagnosis4. Systemic enquiry

SYMPTOM EVALUATION

1. Symptom evaluation means complete elaboration of chief complaint in terms of onset, duration, progress aggravating / Reliving factor ----- etc & then associated features of presenting complaint

Objective is to explain features of P/C against a certain system.

WORKING DIAGNOSIS Here the doctor ability has been assessed to

give a working diagnosis only through a history, means to be explain under a system.

DIFFERENTIAL DIAGNOSIS This portion of HOPI is to access you

span/vision weather you are able to give other possibilities which closely mimic to your diagnosis through analysis of P/C

SYSTEMIC INQUIRY Here a medical students has been accessed

whether he knows about the effects of presenting complaint on the rest of the systems.

PAST HISTORYImportance of brief review of past before

history of presenting of illness -------Here the brief review in the very beginning

needs further elaboration in terms of hospital admission serious ailments, even the suffering since childhood needs to be explained here.

IMPORTANCE OF THE PAST HISTORYAlthough it is small part of the history but

very much sportive for the present diagnosis which have been explained in the history of presenting illness.

It may not only change the present diagnosis but may influence whole treatment scenario.

Explain in terms of examples.

PULMONARY COCK’SA past history of pulmonary tuberculosis may

indicate 1. Re-activation / re-infection of tuberculosis .2. Simply patient may come with the same

disease due to non compliance.3. A sufferer of MDR -------- needs dot therapy

HISTORY OF CHOLECYSTECTOMYPatient might have the presenting complaint

of burbs , flatulence or upper abdominal discomfort .

Here this support of the past history may change the treatment because her the patient simply needs the explanation how to live without gallbladder

Primarily a dietary advise.

RECENT HISTORY OF SURGERY/INFECTION OR VACCINATION

Presenting complaint--------- paraplegia Most likely diagnosis is GB syndrome.

HISTORY OF BLOOD TRANSFUSION May be since childhood A clue for congentinal haemolytic anemia.May present with complication of repeated

blood transfusion -------.

MAY PRESENT OF WITH UTIHistory of the urethral discharge/venereal

exposure ended with the diagnosis HIV .There are so many examples to code which

may influence not only the presence status but also change the treatment sunerio .

So this small part of past history is quite significant.

TREATMENT HISTORYNow again a Caring part of his which not only have a dire consequences of

patient health/life but open new avenue of investigation or even become a charter of crime.

Patient sometimes not know about drugs so advise to bring drugs taken / prescriptions needs to be evaluated.

Even acquire details about Hakeem medication kushtas- ARSENIC INTAKE

NON COMPLIANCE Patient may come with uncontrolled BP/DM ,compliance is the issue / not diagnosis, so

counseling is required. Rather change of treatment .

Some docs just change the dose without knowing previous management – it is quite dangerous.

DRUG ALLERGY Treatment is important regarding H/O drugs

allergy/ Anaphylaxis /Serious side effects, like diarrhea, palpitation, broncho spasm ext. So this information in history will change your treatment plan.

BLEEDING TENDENCY Patient may come with the complain of bloody

vomiting or generalized bleeding tendency may be due to decreased cell lines or decreased platelets because of some medication like warfarin therapy , excessive use of disprin or H/O chloramphinicol / Antineoplastic drugs/ Anti malarial like pyramethamine may cause such problem..

as recent incidence of PIC in last year where many patients have suffered because of bone marrow suppression- presented with bleeding tendency due to there Anti-co-agluents /statin.

MENSTRUAL HISTORYThere the various symptoms regarding

menstrual history like dysmenorrhae ,Menorhegia/ Leading to Anaemia/ most likely diagnosis is for endocrinal disorder.

Similarly a patient come to you with the complain of– Migrain /epileptic fitts have a diagnosis of catamenial epliepsy,

PERSONAL HISTORYImportant in terms of Social & Civil

Circumstances, which may influence the health so it is addressable under various subheading.

ADDICTIONPerson must be asked about any type of

addiction because this part of history may favour diagnosis or current problem.

Addiction may be in terms of alcohol, smoking, Narcotic Abuse including I/V liners even H/O Pan, Niswar or Gutka intake to be asked.

TWO ISSUES ARE IMPORTANTHow much i.e quantity & how long i.e

duration

SMOKING HAZARDS ARE

Peripheral vascular disorder

COPD, CA lung etc Toxic amblyopia

TWO ISSUES ARE IMPORTANTHow much i.e quantity & how long i.e duration

These complications depends upon duration quantity.

ALCOHAL MAY CAUSE

PHYCOSIS

Proximal myopathy Neuropathy

CMP

Wernicke’s encephalopahty

an (acute emergency)

DOMESTIC/ MARITAL RELATIONSHIP

Including Hobbies and different phycological ailments are the by product of these issues.

TRAVEL ABROADMay expose the person to different disease

like yellow fever, sleeping sickness, schistosomiasis or exposure to venereal diseases

FAMILY HISTORYThis part of the history is important in terms

of patient marriage status, numbers of children and their health status including any history of serious ailment from his father and mother side.

Here we are more concerned about the potentially inherited disorders.

AUTOSOMAL DISORDER Genetic basis is quite striking like asthma in

which autosomal recessive character although less apparent but have a definite roll in the spread of disease particularly in OAD.

Next pattern of inheritence in families is about autosomal dominant chraracter like huntingtons chorea or congenital haemolytic anaemias.

Here we have to discourage about the issue of cousin marriage if the family history exist.

X LINKED DISORDERSHere we are more concerned with the sex

linked disorders particularly the diseases effecting over X chromosome.

So haemophelia and vonwillibrand disease are the notorious X linked diseases.

Here females are carrier and males are the sufferers.

In many common disorders like CHD, DM, HTN and dyslipidemia/Atheroma, the mode of inheritance is quite complex and influencet by environmental effects like diet, smoking, obesity and sedentary life style including the depressive illness in families which affect over the outcome of diseases.

OCCOUPATIONAL HISTORY Here the exact nature and description of job

should be asked, not only the present but also past history of job should also be enquired.

In many diseases occupation is directly related to the present illness. Although nature of occupation has been asked in the very beginning during introduction but here it should be evaluated in detail.

Most of the time respiratory diseases are the biproduct of occupational hazards. These depend upon the duration of exposure.

For example ILD is quite common among coal miners. Similarly cotton industry may expose the labourer to OAD.

Brucellosis is quite common in farmers dealing with cattles.

Organophosphate poising is quite common among villagers particularly working on cultivated land .

SOCIOECONOMIC HISTORY This part of the history important in sense of

affordability whether the person is able, either to get the treatment or not.

Statistically certain diseases are more prevailing in different social circles like tuberculosis , C viral disease etc are more common in lower income group.

SUMMARY OF THE HISTORY At the end of the history, medical students

has been asked to summaries the history it means

A medical students should know how to explain briefly about different aspects of the history

Including introduction of patient, his presenting complaint in terms of likely diagnosis , a few differential and relevant systemic inquiry should be explained briefly.

General physical examinationFor the general physical examination we have

to have a certain sequagel.Through the sequence of general physical

examination the first and foremost issue isTo get the consent of the patient for

examination.• Here the doctor has to introduce him self

and has to explain the patient, for what purpose doctor want to examine the patient.

• This consent is very important in the sense the doctor has to make a physical contact for examination. Therefore the patient should be comfortable and confident for examination.

POSITION OF THE PATIENTEvery system of the body has been examined

through making a definite position of the patient for the said system which should be convenient not only for the patient but also for the doctor.

For GIT the patient should lie in supine position with the hands along the side of the body.

EXPOSURE OF THE PATIENTThe person should be exposed properly for

examination In GIT, the person should be exposed up till

the mid chest and bellow up till the groins.But remember one thing, exposure does not

mean indecent exposure but take into account the socioeconomic, cultural and religious norms of the society.

VISUAL SURVEY OF THE PATIENT.Always approach to the patient on the right

side and after taking consent, make the position, do the proper exposure and get

An aerial/ panoramic view of the patient from head to toe then come to foot end of the patient, sit at the level and do the same exercise.

During the visual survey you have to notice the following issues.

1. Appearance of the patient 2. Apparent age 3. Nutritional status4. Level of consciousness 5. Behavior of the patient

Therefore the doctor has to comment about these five expects during the aerial view.For example, you can make statement like this

A cooperative middle age male looking emaciated lying on bed comfortably well oriented in time place and person.

VITALS OF THE PATIENTRegarding vitals doctor has to comment

about 1.Pulse2.B.P3.Temp.4.R R5.After taking the vital doctor has to

summaries the statement like pulse is 76/min. Regular in rhythm patient is narmotensive, afebrile, while respiratory rate is 16/min.

Signs of the patient • Doctor is required to check the following

signs for general physical examination.1. Anaemia2. Jaundice 3. Cyanosis4. Edemia 5. Clubbing6. Lymph nodes

Anemia By definition when hemoglobin level is below

the normal range with respect to patient age and sex Sites for anemia Anemia has been checked over skin, mucous

membrane, Conjunctiva and over the palms /nails.

Rest of the sign depends upon the severity and type of anaemia but in general physical examination one has to comment simply over the presence of anaemia.

The main symptoms are tiredness , fatigability , SOB, heavy headedness and palpitation.

JAUNDICE It is the yellow pigmentation of skin and sclera.Caused by elevation of serum bilirubin.Clinically jaundice is evident when serum

bilirubin level is more then 2 to 2.5mg/dl collectively.

Sites for Jaundice . Skin Palmer Creases Sclera

Pathologically Jaundice is classified as Non obstructive Obstructive jaundice

OEDEMABy defination oedema means accumulation of

fee fluid in interstitinal space. as you know body fluid is present in two

compartments . Vascular Extra vascular

Extra vascular is further divided into two compartments.intera cellular Extra cellular/ interstitial fluid.

Clinically patient may come with complain of swelling mainly over the extremities .

This swelling may be localized or generalized.

Nature of swelling If the swelling has indentation at the site of

pressure, It is called pitting in nature now it may be sign or symptoms.

If swelling has no indentation, it is called non pitting oedema .

It can be explain through various examples and the accumulation of fluid is due to increased hyodostatic pressure in both pitting and non pitting oedema.

It may be due to decreased oncotic pressure

Sites Dorsum of foot Distal/3 of tibiaSacrumBellow medial malleolus. The pressure of finger at the said site should

be maintained at least for thirty seconds.

EtiologyIt is variable If it is due to increased hydrostatic pressure

then the causes are CCF Constrictive pericarditis. Cor-pulmonale Drugs Iatrogenic

Decreased oncotic pressure may be due to.CLDNephrotic syndromMalabsorption

Cyanosis By definition it is a bluehes discoloration of

skin and mucous membrane due to Ecessive accumulation of reduced Hb in

blood at least 5gm/dl of reduced Hb. In severe anemia cyanosis may be absent.In polycythemia it may occur quickly.

TypesCentral because of systemic insult. Main cause is inpimpaired oxygenation of

blood.

Defective ventilation/ perfusum due to respiratory disease.

Admixture of deoxygenated blood that is venous into systemic circulation e.g reversal shunt in congenital heart diseases like VSD/ fallots tetrollogy/ SBE.

Peripheral cyanosis It is vascular in origin e.g raynauds

phenomenon/raynauds disease.Sites.

Peripheral cyanosis has been seen over extremities which are cold and by warning cyanosis may become absent.

Central cyanosisCentral cyanosis has been checked over

extremities which are warm and in mucous membrane that is under surface of tongue and tip of Nose.

ClubbingIt is a morphological change in the shape of

nails.

Normaly nails are curved from the side to

side and straight longitudenaly.

Normaly there is an angle between nail bed

and soft tissue junction seen as a gap if

straight line is drawn bridging the cuticle and

soft tissue.

Pathology and grades of clubbingPathologically there is deposition of vascular

spongy tissue. Grades

Grade - 1. Spongy tissue is deposited is under nails angle which has

been obliterated – GAP absent.

Grade -2. Nails become convex from side to side and from above

downward and the shape of the nails may become like inverted spoon.

Grade -3. Terminal phalanges will become drumstick

appearance.

Grade -4Disease may extend to lower and of long bones

causeing painful swelling of wrist at the lower ends of radius and ulna called pulmonary osteodystrophy .

In the examination of GIT, clubbing is not so common but only present in malabsorption syndrom.