History Taking in Medicine and Surgery for Final MBBS practical exams

History Taking

The Medical Post (www.themedicalpost.net)

History taking in

Medicine and Surgery

for final MBBS

practical exams

FIRST EDITION

History Taking


Cerebrovascular Accidents (Stroke)

Common presenting complaints –

Weakness on one side of the body.

Facial deviation or asymmetry.

Loss of consciousness.

History of presenting illness –

In such cases the history should ideally start as my patient was apparently

asymptomatic _ days back when he developed weakness on one side of the

body. The weakness was acute/insidious in onset and gradually

progressive/static in nature.

Mention what activity the patient was involved in at the time when this

weakness developed.

Whether the patient fell down and hurt themselves as the attack occurred.

Important points during the pre ictal phase: Any history of headache, vomiting,

dizziness.

Facial deviation: Ask to which side the angle of mouth/face is deviated, any

history of slurred speech, drooling of saliva, difficulty in drinking liquids and

regurgitation of food after the stroke attack.

Seizures: History of abnormal body movements, tongue biting, up rolling of eyes

and frothy secretions from the mouth.

Embolic evidence – History of chest pain, dyspnea and palpitations.

History Taking


Incontinence of stools and urine.

Blurring/loss of vision.

Any history of recent head injury/trauma.

Past history –

Rule of any previous episode of TIAs.

Any similar episodes in the past.

Any history of significant medical condition in the past.

Predisposing factors like Hypertension, Diabetes, Smoking, and Alcohol.

History of intake of drugs like OCPs, Aspirin, Warfarin, Hormones, etc.

Family history of stroke.

Ideal CNS Diagnosis:

History Taking


Chronic Obstructive Pulmonary Disorder


Sudden increase in the shortness of breath

Cough (More with patients of Chronic Bronchitis)


There are two ways to present a case of COPD. Either start the history dating

back to so and so years when the first episode of SOB occurred, or you could

present the acute episode first by saying how many days back the patient was

apparently asymptomatic plus with elaboration of the previous episodes in the

past history.

Shortness of breath: Onset (usually insidious) - initial MRC grading –

progression (usually there is sudden progression to the current condition) –

current MRC grading.

Ask for Orthopnea and PND to rule out any cardiac cause.

Cough: Onset, progression, about sputum (Cases of chronic bronchitis may -

complain of cough as their chief complaint), hemoptysis. Associated chest pain?

Ask for any seasonal variation/ exposure to air borne irritants on the job.

Fever: Onset, pattern, maximum temperature recorded or not, associated with

chills and rigors? A patient of COPD usually presents in acute exacerbation

either because of infection or rupture of emphysematous bullae.

History of weight loss and loss of appetite. (Note that emphysematous patients

are usually thin built).

History Taking


Any history of bluish discoloration of the generalized skin. (For features of

hypoxia).

Complication:

History of tremors (salbutamol use).

Ask for bowel habits (constipation because of hyperkalemia).

Headache, mental confusion (features of CO2 narcosis).

Personal history:

Whether the patient smokes? Duration of smoking. Calculate the number of

pack years. Number of pack years = (number of cigarettes smoked per day ×

number of years smoked)/20 (1 pack has 20 cigarettes).

If quit smoking – Why and When did he quit?

Family history of similar illness.

Past history:

Number of episodes in the past.

Drug intake – mention all the drugs the patient is currently taking.

How the patient’s condition is affecting his/her quality of life: missed work,

disrupted routines and depression.

Ideal Respiratory System Diagnosis:

History Taking


Alcoholic Liver Disease


Yellowish discoloration of the skin.

Abdominal distension.


Yellowish discoloration: Onset, progression (usually it is first noticed in the

sclera and then it becomes evident on whole of the body).

Abdominal distension: Onset, progression. Associated abdominal pain and

difficulty in breathing (as massive ascites pushes the diaphragm up and makes

difficult for the patient to take deep breaths).

Upper GI Bleed – History of Hematemesis.

Hepatic Encephalopathy: Ask the patient party for any history of

disorientation/restlessness, tremors, excessive sleep.

History of foul smelling odor; fetor hepaticus.

Alcohol withdrawal: mental confusion, irrelevant speech, agitation

/aggressiveness.

Ask any history of loss of hair.

Also rule out features of congestive cardiac failure from history.

Personal history:

History of intake of alcohol – duration of drinking – current situation.

History of intravenous drug abuse.

History Taking


Bowel habits – pale stools (obstructive jaundice), black tarry stools (portal

hypertension).

Urine – Dark in color? (Suggesting obstructive jaundice).

Past history:

Similar episodes in the past.

History of hepatitis in the past.

Ideal Diagnosis –

History Taking


Rheumatic Heart Disease


Shortness of breath

Hemoptysis


Shortness of breath: Onset (usually insidious) - initial NYHA grading –

progression (usually there is sudden progression to the current condition) –

current NYHA grading.

Ask for Orthopnea and PND (orthopnea indicates more severe disease).

Cough: Onset, progression, about sputum. (Cases of chronic bronchitis may -

complain of cough as their chief complaint). Associated chest pain?

History of palpitations.

Swelling of both the limbs: (due to congestive cardiac failure/RHF). Explain

about the onset, progression.

Abdominal distension / abdominal pain.

History of dizziness/syncope/loss of consciousness/fatigue – due to decreased

cardiac output.

Personal history:

Smoking- Diabetes – Hypertension – Exercise habits – Eating habits.

Family history of similar illness.

History Taking


Past history:

History of similar episodes in the past – number of hospital admissions.

History intake of intramuscular penicillin injections every 21 days or intake of

Phenoxybenzyl penicillin 250 mg PO BD in the past.

Ideal diagnosis –

History Taking


Thyroid Swelling / Thyrotoxicosis / Multi nodular Goitre

XYZ 57 years old female come from Palpa to the Manipal Teaching Hospital on

09/05/2010 and was examined by me on 13/05/2010

The chief complaints were: Rapid increase in the size of the swelling with pain in

the mid line of the neck for the past 2-3 months.

History of presenting illness:

The history dates back to 30-40 yrs back when the pt noticed a small marble

sized swelling on the left side near the mid line of the neck at the age of 16 yrs

in the mirror and also when told the neighbor.

Initially the swelling was not associated with pain and was stationary and after

16 yrs interval the pt noticed similar welling on the right side of the neck which

was also stationary and also not associated with pain. But since the last 2-3

months there has been rapid increase in the size of the swelling on the both

side and its associated with pain which is insidious in onset intermittent, dull

aching type and radiating towards the back of the neck and the upper back of

the shoulder. The pain was relieved on rest and no aggravating factors were

found.

No history of other swellings in the body, no difficulty in swallowing solid of

liquid food, no difficulty in breathing, no hoarseness of voice, no loss of

appetite, no loss of weight, no diarrhea or constipation.

No history of chest pain, palpitations, nervousness, irritability, difficulty in

sleeping, no tremors and no weakness of the limbs, no heat or cold intolerance,

no sweating, no decreased or double vision, no ocular pain or redness.

History Taking


Past history:

No history of TB, DM, HTN, Asthma. No history of surgery or any prolonged

hospitalization.

Personal history:

Non smoker, non alcoholic, normal bowel bladder and sleep habits.

Family history:

No similar swelling among the family members seen but however there has

been significant number of women suffering from similar neck swellings in the

locality.

Menstrual history:

The pt. attended menopause at the age of 40, no history of post menopausal

bleeding or any per vaginal discharge.

Treatment history:

The pt. has not received any treatment for this condition.

The pt. has been planned for surgery.

EXAMINATION

The pt. is moderately built, well alert, cooperative and well oriented to time

place and person.

The Vitals were in the normal range.

There is no pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy.

History Taking


Local examination of the Neck-

1. Inspection-

The swelling moves up and down with deglutition.Does not moves with the

protrusion of the tongue.

The swelling is situated infront and side of the neck extending laterally uptill the

sternocleidomastoid muscles and below upto the suprasternal notch and

involves whole of the front of the neck.

Both the lobes of the thyroid glands are enlarged and the right lobe appears to

be more prominent. The right lobe is about 10*8cm and the left lobe about

7*6cm.

Trachea is not visible.

Dilated veins are seen at the lower border of the swelling.

2. Palpation-

I confirmed my inspection findings.

No raised temperature, No tenderness.

Swelling moves with deglutition.

The swelling is heart shaped.Size- Rt lobe – 13cm vert. and 9cm horz. Lt lobe is

9cm and 7cm respectively., Isthmus is 10cm vertically.

It is variable in consistency.

Margins are well defined.-Trachea not palpable.Skin over the swelling can be

pinched out.

No pulsations and thrill were felt.

Mobility is present from side to side and not vertically.

Swelling is attached to the sternocleidomastoid muscle and on making the neck

taught the mobility of swelling is restricted.

Carotid pulsations are felt at the ant. border of the sternocledomastoid muscle.

History Taking


Percussion-

Superior mediastinum is resonant.

Auscultation-

No bruit over the swelling heard.

There were no signs of the toxicity present.

Special Test-

Kocher test is positive.

Pembertant sign is negative.

History Taking


Hernia/Hydrocele


[HERNIA] Swelling on the left/right groin since the past _

days/months/years.

[HYDROCELE] Swelling on the left/right scrotum since the past _

days/months/years.


Swelling: Onset (usually spontaneous) – site (left / right groin) - initially of a size

similar to some object (e.g. marble), progression (usually gradual to the current

size) – extent (groin to the scrotum/scrotum to the groin).

Change in the size of the swelling on lying down/standing position.

Increase in the size of the swelling on coughing, defecation, etc.

Note that in Hydrocele there is no change in the size of the swelling during

standing, walking, with strenuous activities or on lying down. Also there is no

pain and other symptoms.

Features of strangulation/toxicity :

Any sudden increase in the size of the swelling.

Any color change ?

Pain over the swelling.

History of vomiting, fever.

Pain: site of pain, character, radiation, relation of pain with straining (usually the

pain increases on straining), relieving factors.

History Taking


History for straining factor (to find the cause of hernia) -

Cough, Constipation

Predisposing factors like – Bronchial asthma, Diabetes, Tuberculosis,

Hypertension.

Bladder habits: Urgency, frequency, narrowing or irregular urinary stream

(features suggestive of BPH).

History Taking


Breast Lump


Swelling in the right/left breast.

Pain in the breast/ over the swelling.


Swelling: Onset, site, size, progression. How did the patient notice the swelling

(usually on breast self examination).

Any swelling in the axilla or the opposite breast.

Pain: site, duration, character (usually dull aching), relationship with the

swelling and the menstrual cycle.

Fever (Swelling, pain and fever are characteristics of breast abscess).

Ulcer (usually associated with carcinoma of breast) – explain with site, duration,

discharge.

Nipple discharge.

Any history of loss of appetite and weight. (Suggestive of carcinoma).

History suggestive of metastasis -

Any history of cough, breathlessness, hemoptysis, chest pain.

Any history of low back pain, and radiation of pain to the lower limbs.

Any history of headache, vomiting, weakness of any limbs, any history of

seizures.

History Taking


Personal history:

Menstrual history – age at menarche.

Obstetric history – age at first pregnancy, total number of pregnancy, number of

abortion, last child birth.

History of lactation.

History of use of OCPs or any hormonal therapy.

History Taking


Road Traffic Accident


Loss of consciousness/headache following a road traffic accident or fall

from height. [HEAD INJURY]

Difficulty in breathing. [CHEST INJURY]

Drowsy. [SHOCK / BLUNT ABDOMINAL TRAUMA]


Usually start the history as the following,

My patient was apparently asymptomatic 4 hours back when he met with a

road traffic accident following which is banged his/her head on the road (in a

case of head injury).

Details about the accident :

Whether the patient was a driver/passenger/pedestrian.

The impact occurred from which side.

Wearing a seat belt or not.

Did he strike on anything after the accident. If yes then what body parts

were involved?

Road conditions – dry, wet, snow/ice, banged on the divider?

Who brought the patient to the hospital and how?

Important history taking in a case of head injury,

Any period of loss of consciousness following the accident. Duration of

the period. Any lucid interval present (it means any history of the

History Taking


patient being restless, talkative, irritable, confused, etc. before

becoming completely unconscious).

Vomiting – usually in a case of underlying head injury there are multiple

episodes of vomiting; projectile in nature. (It is because of the raised

intracranial pressure).

Headache.

Blurring or loss of vision following the accident.

Prolonged confusion.

Abnormal body movements (seizures).

In case the patient presents after a few days of the accident, we must ask for if

the patient is having difficulty in concentration – increased mood swings –

lethargy – aggression – altered sleep habits.

Other important points to be asked,

Difficulty in breathing (to rule out chest injury).

History Taking in Medicine and Surgery for Final MBBS practical exams

Health & Medicine

Transcript of History Taking in Medicine and Surgery for Final MBBS practical exams