CLINCAL Quiz 1,2,3,4

Medical History Taking Basics

• History taking involves a physician gaining information by asking specific questions to a patient.
• Obtaining an accurate history is a critical first step in determining the etiology of a patient's illness.
• Diagnosis in medicine depends on clinical history, physical examination, and investigations.
• It takes practice, patience, concentration, and understanding to take a true history.
• A true history relies on good communication between the patient and doctor.

How to Greet a Patient

• Greet the patient by name.
• Make eye contact.
• Display confidence.
• Explain everything being done and review the plan of care, ensuring the patient is involved in decision-making.
• Maintaining patient privacy is essential.

Components of History Taking

• Personal history
• Chief complaint
• History of present illness
• Past history
• Family history
• History of allergies
• Social and economic status
• For females, menstrual and obstetric history

Personal History

• Name
• Age
• Sex
• Occupation
• Marital status
• Residence
• Special habits

Special Habits

• Smoking: Smoking can damage every part of the body; it causes cancers of the head, neck, and lungs.
• Pack-year calculation: number of packs per day multiplied by the number of years smoked.
• Alcohol and drugs should also be considered.

Presenting Complaint

• Allow the patient to express their complaints in their own words.
• Do not put leading questions to the patient.
• Current complaints and their duration should be noted in chronological order.
• Example: Difficulty in breathing since this morning.

History of Presenting Complaints

• Onset
• Nature
• Course
• Associated symptoms
• The duration of each symptom
• Aggravating and relieving factors
• Mnemonic: OLD CARTS (Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, Severity)

Past History

• Ask if the patient presented with similar complaints in the past, and if so, when and how frequently.
• Note any history of blood transfusion, operation, medication, drug sensitivity, or travel abroad.

Drug Sensitivities

• Some people are allergic or sensitive to drugs not harmful for most persons.
• Aspirin, penicillin or related antibiotics may induce allergic reactions or sensitivities.

Family History

• Obtain details of the family history.
• Ask if there are any illnesses that run in the family.
• A basic family tree and a focus on first-degree relatives is ideal.

History of Allergies

• Allergies are hypersensitive responses from the immune system when in contact with foreign substances.
• Common presentations: cold, cough, sneezes, rashes, facial edema
• Common allergens: dust, mites, pollen, some kinds of foods, and drugs

Social and Economic Status

• Enquire about the patient's family lifestyle, daily habits, and diet.
• Learn nature of the patient's work to see if the patient was sedentary or performing hard work.
• Determine overcrowded home setting aids in communicable disease spread and sanitation considerations.
• Note if there is a presence of pets in the house.

Menstrual History

• Includes age of menarche.
• Length of each cycle.
• Check if cycles are regular or irregular.
• Find the volume of blood loss in each menstrual cycle.
• Check the age of attainment of menopause.
• Determine if there is post-menopausal bleeding.

Obstetric History

• Includes the number of times the patient has conceived.
• The number of times pregnancy was carried to term.
• The number of abortions
• The number of living children, their ages, and the age of the last child delivered.
• Time interval between pregnancies/abortions.
• The mode of delivery (vaginal, forceps assisted, or caesarean)
• Development of oedema in the legs, hypertension or seizures in the antenatal or postnatal period.
• Gestational diabetes
• Tubectomy or Hysterectomy

Symptomatology

• Includes symptoms like fever, shortness of breath, cough, diarrhea, headache, rheum, hemoptysis, aching muscles, vomiting, and fatigue.
• Symptom: Any deviation from health that can only be perceived or felt by the patient.
• Syndrome: A set of symptoms and signs associated with and characteristic of any particular disease.
• Sign: A symptom with a physical manifestation that can be detected by others.

Onset

• Acute: Less than 4 weeks
• Subacute: 4-12 weeks
• Chronic: More than 12 weeks

Course

• Relapse: Return of the original symptoms and signs of the disease.
• Exacerbations: Sudden worsening in the severity of the symptoms/signs.
• Remission: Temporary improvement in the symptoms & signs of a disease without curing the underlying disease.
• Sequela: Abnormal condition or complication that is due to the original and remains developed after it resolves.

General Symptoms

• Fatigue

Cardiovascular Symptoms

• Dizziness
• Shortness of breath
• Palpitations
• Chest pain/discomfort
• Fainting

Chest Pain

• is one of the most common subjective symptoms that causes alarm to the patient
• Angina pectoris: Chest pain or discomfort that keeps coming back due to lack of blood or oxygen going to the heart

Respiratory Symptoms

• Dyspnea: Difficulty or awareness of breathing
• Cough
• Hemoptysis

Cough

• It is a physiological protective mechanism which is characterized by explosive expectoration against a closed the glottis following a deep inspiration.

Hemoptysis

• Coughing of blood.
• Types include haemorrhage from lungs, bronchial tree and trachea and haemorrhage from nose, pharynx & larynx.
• Results can include ruptures and lacerations.

Gastrointestinal Symptoms

• Dysphagia
• Dyspepsia
• Anorexia
• Vomiting
• Hematemesis
• Diarrhea
• Constipation
• Hematochezia
• Melena

Specific Gastrointestinal Symptoms

• Dysphagia and Odynophagia: Difficulty and pain in swallowing.
• Dyspepsia Combination of indigestion, pain, distention, acidity, nausea (and Hunger Pains).
• Anorexia: Reduced appetite
• Vomiting: The forceful expulsion of a part/whole of the stomach content through the esophagus and mouth.
• Hematemesis: Vomiting of blood
• Diarrhea: Greater than 200-300 gm/day, greater than 3 times a day with liquid consistency
• Constipation: Passage of hard stools with a reduced frequency of less than 3 times a week.
• Hematochezia: Rectal bleeding from anus or rectum
• Melena: dark black, tarry stool that is associated with upper gastrointestinal bleeding.

Genitourinary Symptoms

• Hematuria
• Dysuria
• Enuresis
• Anuria
• Oliguria

Specific Genitourinary Symptoms

• Hematuria: Presence of red blood cells(erythrocytes) in the urine.
• Dysuria: Painful urination. Difficulty in urination is also sometimes, but rarely, described as dysuria.
• Enuresis: A repeated inability to control urination.
• Anuria: Nonpassage of urine and less than 50 milliliters of urine in a day. Often caused by failure in the function of kidneys.
• Oliguria or hypouresis: Low output of urine. Classified clinically as an output more than 80ml/day but less than 400ml/day. Can be dehydration, kidney failure, or hypovolemic shock.

General Physical Examination

• One important rule is that the doctor always stand at the patient's right hand side

Preparing Physical Examination

• Introduce self to patient.
• Shake patient's hand.
• Ensure relevant equipment available
• Confirm privacy
• Get permission from patient.
• Hand washing is important, and wash palms, finger tips, back of hands, and thumbs.

General Examination

• Includes assessing appearance of patient, corporation, consciousness, build, nutrition assessment, decubitus, gait and posture,and vital signs.

Appearance of the Patient

• Normal: Normal appearance
• Toxic: Flushed face due to VD effect of infection
• Emaciated "Cachextic": Seen in late-stage cancer fatigue with wasting of face muscle & fat.
• Ape-like: Seen in acromegaly in large jaw, tongue, nose & ears
• Moon face: As in Cushing's syndrome

Consciousness

• Rapid and initial assessment of a patient's conscious level can be made using:
  • the AVPU Scale (Alert, responds to Voice, responds to Pain, Unresponsive)
  • the Glasgow Coma Scale (GCS) with a total score of 3-15

Glasgow Coma Scale

• Includes eye opening response(4 points max), verbal response( 5 points max), and motor response.(6 points max)
• Minor Brain Injury is 13-15 points while Moderate Brain Injury is 9-12 points; Severe Brain Injury is 3-8 points.

Built

• It is a measure of overall body size of individual and include both stature and body mass.
• Stature is measured from head to heal and the span is measure from finger to finger along middle phalanges.
• Build includes gigantism, normal growth and dwarfism.

Nutrition

• Includes, BMI, fat, protein, vitamins

Clinical Assessment of Nutrition

• BMI: Body mass index = weight in kg/height in m^2
• Underweight: <18.5 BMI
• Normal weight: 18.5-24.9 BMI
• Overweight: 25-29.9 BMI
• Obese: 30-39.9 BMI
• Morbidly obese: >40 BMI
• Anthropometric measurement: Skin fold thickness (indicator of fat); mid arm circumference is the indicator of muscle mass(#Normally is 25cm); patient's waist circumference

Specific Waist Circumference

• Waist circumference was seen and associated in definition of the metabolic syndrome and to risk factor associated

Decubitus and gait posture

• Orthopnea: It is the condition where dyspnea is lying down which is relieved by sitting upright
• Platypena: This occur when a person experiences dyspnea in upright position which is relieved by lying down
• Professor attitude: Patient stands supporting his extended arms on a surface like a table
• Prayer position - Patient prefer to lean forward
• Finger pointing to chest

Complexion

• Refers to the color of the skin and mucous membranes
• Included in assessing complexion: pallor, jaundice, and cyanosis.
• Normal complexion is determined by skin, tissue pigments, blood, and degree of oxygenation.

Pallor

• Involves the color of skin minus its redness.
• It gives an idea about the level of hemoglobin or blood perfusion.
• Detection sites include the inner surface of the lips, the palm of the hand especially the palmer creases, the nail bed, and mucous membranes such as the conjunctiva & buccal.

Types of Pallor

• Anemia
• Low Cardiac Output(COP) in Left-sided heart failure, MI (Myocardial Infarction, or heart attack), shock, etc.
• Drugs that cause peripheral VC(Vasoconstriction) as a type of vasopressin
• Edema of the face and of the outer skin layer in cases of anasarca
• Increased skin thickness as in hypothyroidism
• Decreased skin pigmentations as in panhypopituitarism

Cyanosis

• Bluish discoloration of skin & mucous membrane due to increased percentage of reduced hemoglobin (≥5 GM) in capillary blood Normally does not increase 2.5.

Types of Cyanosis

• Central cyanosis is usually cardiac or respiratory causes
• Lateral edges on the surface of the tongue are common sites
• Peripheral sites are the nail bed, lip's outer surface, tip of nose, ear pinna
• Differential Cyanosis is a condition with cyanosis in half one area of the body is normal while the opposing half is cyanotic

Conditions That Affect Oxygen Saturation

• COPD (Chronic obstructive pulmonary disease)
• Asthma
• Congenital heart defects
• Heart disease
• Collapsed lung
• Pulmonary embolism (blood clot in the lung)
• Anemia (reduced red blood cells)

Jaundice

• Results from an abnormally high accumulation of bilirubin in the blood, leading to yellowish discoloration of the skin and deep tissues.
• Detectable when serum bilirubin concentration rises above 50 µmol/L (3 mg/dL).
• The sclera of the eye, which contains considerable elastic fibers, is usually one of the first structures in which jaundice can be detected.
• The major causes of jaundice are excessive destruction of red blood cells, impaired uptake of bilirubin by the liver cells, decreased conjugation of bilirubin, and obstruction of bile flow in the canaliculi of the hepatic lobules or in the intrahepatic or extrahepatic bile ducts.

Assessment points

• Assessment point is with jugular venous pressure which use jugular vien in the heart.

Upper Limb Examination

• Includes checking for clubbing.
• Painless enlargement of distal phalanges.
• First degree clubbing (window sign missing), Second degree (parrot peak) or Third degree (drumstick)

Lower Limb Examination

• Considers pitting edema, with different grades reflecting depth of the pit in mm (2, 3-4, 5-6, 8).
• Includes non-pitting edema.