Simple diagnosis and

producer

Dr Osman Abas Mohamed

MBChB
History taking and physical
examination
 Definition of history taking:
It is the process of obtaining relevant information from the
patient or patient’s caretaker (such as the mother or father) for
the purpose of making a diagnosis.
or,
It is typically obtained when a physician sees a patient for first
time in general medical setting, or when a patient is admitted
to hospital.
•“More errors are made because of
inadequate history-taking
and
superficial exam
than any other cause.”
 Goals of the history
• To determine why the patient/parent came to see the physician.

• To determine what the patient/parent is worried about most and why.

• To strengthen the physician/patient/parent relationship and thus the

therapeutic alliance by observing, listening and conveying empathy.
• Direct appropriate examination and investigation.

• Reach a correct diagnosis (or form a differential diagnosis)

 A Sample History
• About 60– 70 % of diagnoses are based
mainly on history
 Patient participation
• Good communication is essential in good patient care;
• Poor communication leads to conflicting messages and patient
dissatisfaction ,
• How long will you have?
• How will you sit?
• Non-verbal communication
• First impressions are important. Your demeanor, attitude and dress
influence your patient from the outset.
The stages of clinical problem-solving should be followed step by step, in order to arrive at the best
possible diagnosis and to plan appropriate management. The sequence of events used in making a
diagnosis is:
• history-taking
• physical examination
• selection of laboratory tests and interpretation of results
• use of diagnostic facilities, e.g. X-ray, ultrasound.
The first step to make a diagnosis of a disease is the exploration of the medical history,
followed by the physical examination of the patient. The second step is the ordering of diagnostic
investigations.
The time needed to gather a medical history depends on the nature of the problem. The
physician should aim to spend at least 10 minutes with every patient, but complicated
problems may require longer. Physicians should familiarize themselves with local terminology used
by the community to describe clinical conditions and diseases.
Elements in a clinical history;
• presenting complaint.
• history of present illness.
• Past medical history.
• drug history.
• Family history.
• social history.
• Occupational history.
 Questions are asked in order to explain the chief complaint and
clarify the likely differential diagnoses. Where there are several
symptoms, it useful to ask the order in which they occurred. Questions
should always be specific and useful. One of the most useful questions
is “Have you ever had the same problem before?”.
With experience, two or three specific questions will lead the
clinician to the most likely diagnosis. The clinician will also learn which
questions related to the other “systems” could be relevant to the
patient’s problem.
• After introducing yourself ;
• confirming your patient’s:-
• name,
• age,
• date of birth,
• marital status and
• current occupation.
• establish your patient's presenting complaint.
Chief complaint: is the main problem that brings a patient to a doctor
and is the focus of the medical evaluation, often in the patient's own
words.
In the patient's or informant's words.
Description of the presenting complaint, in chronological order.
Brief statement of primary problem (including duration) that caused
family to seek medical attention.
It is important to establish the duration of each complaint.
History of the Present Complain
This is the most important part of history.
Details of the chief complaint are expanded.
• How and when the condition begin
• Progress of the condition, chronology or sequence
• Aggravating and alleviating factors
• Relevant negatives information should be included if they contribute to the
diagnosis or help exclude other possibilities.
Follow-up enquiry ,
e.g. pain - site, nature, frequency, radiation, aggravating & relieving factors,
associated features
e.g. seizure – onset, characteristics, duration, post episode
 Cont…
• A helpful statement includes when was the patient last
entirely well.
• Review of Systems. A checklist for pertinent information that
might have been omitted. "Are there any symptoms related
to . . .?
• There is no need to repeat previously recorded information
in writing a Review of Systems.
 Cont…
• If there is more than one complaint, ask which complaint
came first, which was next and finally, which came last. You
should then present these complaints in order beginning with
the one that came first.
• Always start by “open questions” and leave “closed
questions” ; a “Yes” or “No” questions till end to complete
data.
 Cont…
• Any significant prior laboratory or radiology studies
should be noted here.
• Child maltreatment should be considered if the history
and physical exam are not consistent with one another
or if there is a delay in seeking care for a serious
injury.
 History of the Present complain: HPC-
Theme
• History of the Present Illness
• (where? what? when? How?...) directed at the chief complaint(s).
• Review of other systems
• Support a diagnosis
• Exclude a diagnosis
• Assess severity of a disorder
• Negative information should be included if contribute to
diagnosis or exclude other possibilities.
Past Medical History
Hospitalizations
Surgeries
Medications and drug allergies
Recent travel
Recent exposure
Injuries
Communicable diseases