HISTORY AND EXAMINATION

AND INVESTIGATION
Making medical notes
• All medical and paramedical professionals have a duty to record their input and care of
patients in the case notes.
• These form a permanent legal and medical document.
There are some basic rules.
• Write in blue or black ink; other colours do not photocopy well.
• Date, time, and sign all entries; always identify retrospective entries.
• Be accurate.
• Make it clear which diagnoses are provisional.
• Abbreviations are lazy and open to misinterpretation; avoid them.
• Clearly document information given to patients and relatives.
• Avoid non-medical judgements of patients or relatives.
Basics
• Always record name, age, occupation, and method of presentation.
• Cover all the principal areas of medical history:
• Presenting complaint and past history relevant to it.
• Other past medical history, drug history, and systematic enquiry.
• Previous operations/allergies/drugs.
• Family history, social history, and environment.
Presenting complaint
This is a one- or two-word summary of the patient’s main symptoms,
e.g. abdominal pain, nausea and vomiting, swollen leg, PR bleeding.
• In emergency admissions, do not write a diagnosis here
(e.g. ischaemic leg).
The diagnosis of referral may well turn out to be wrong.
• In elective admissions, it is reasonable to write: ‘elective admission
for varicose vein surgery’.
History of presenting complaint
• This is a detailed description of the main symptom and should include the relevant
systems enquiry.
• Try to put the important positives first, e.g. right-sided lower abdominal pain, sharp,
worse with moving, and coughing, anorexia 24h.
• Include the relevant negatives, e.g. no vomiting, no PR bleeding.
• Be very clear about the chronology of events.
• In a complicated history or with multiple symptoms, use headings, e.g. ‘Current episode’,
‘Previous operations for this problem’, ‘Results of investigations’.
• Summarize the results of investigations performed prior to admission systematically:
bedside tests, blood tests, histology or cytology, X-rays, cross-sectional imaging, specialized
tests.
Past medical history
• Ask about thyroid problems, tuberculosis (TB), hypertension,
rheumatic fever, epilepsy, asthma, diabetes, ischaemic heart disease,
stroke, and previous surgery, specifically.
• List and date all previous operations.
• Ask about previous problems with an anaesthetic.
• Asking ‘Have you ever had any medical problem or been to hospital
for anything?’
at the end often produces additional information.
Systematic enquiry
• This is extremely important and often neglected.
• A genitourinary history is highly relevant in young females with pelvic pain.
• A good cardiovascular and respiratory systems enquiry will help avoid patients being cancelled because they
have undiagnosed anaesthetic risks.
• Older patients may have pathology in other systems that may change management, e.g. the patient with
prostatism should be warned about urinary retention.
• Cardiovascular. Chest pain, effort dyspnoea, orthopnoea, nocturnal dyspnoea (see b p. 58), palpitations,
swollen ankles, strokes, transient ischaemic attacks, claudication.
• Respiratory. Dyspnoea, cough, sputum, wheeze, haemoptysis.
• Gastrointestinal. Anorexia, change in appetite, weight loss (quantify how much, over how long).
• Genitourinary. Sexual activity, dyspareunia (pain on intercourse), abnormal discharge, last menstrual period.
• Neurological. 3 Fs: fits; faints; funny turns.
Social history
• At what time did they last eat or drink?
• Ask who will look after the patient, Do they need help to mobilize?
• Smoking and alcohol history
Tips for case presentation
• Practise. Every case is a possible presentation to someone!
• Always ‘set the scene’ properly, Start with name, age, occupation, and any key medical facts together with the main presenting
complaint(s).
• Be chronological, Start at the beginning of any relevant prodrome or associated symptoms; they are likely to be an important part of
the presenting history.
• Be concise with the past medical history. Only expand on things that you really feel may be relevant either to the diagnosis or
management, e.g. risks of general anaesthesia.
• For systematic examination techniques, see the relevant following pages.
• Always summarize the general appearance and vital signs first.
• Describe the most significant systemic findings first, but be systematic—‘inspection, palpation, percussion, and auscultation’.
• Briefly summarize other systemic findings. Only expand on them if they may be directly relevant to the diagnosis or management.
• Finally, summarize and synthesize—don’t repeat. Try to group symptoms and signs together into clinical patterns and recognized
scenarios.
• Finish with a proposed diagnosis or differential list and be prepared to discuss what diagnostic or further evaluation tests might be
necessary.
THE COMMENST SYMPTOM
Pain
Pain anywhere should have the same features elicited.
These can be summarized by the acronym SOCRATES.
• • Site. Where is the pain, is it localized, in a region, or generalized?
• • Onset. Gradual, rapid, or sudden? Intermittent or constant?
• • Character. Sharp, stabbing, dull, aching, tight, sore?
• • Radiation. Does it spread to other areas? (From loin to groin in ureteric pain, to shoulder tip in
diaphragmatic irritation, to back in retroperitoneal pain, to jaw and neck in myocardial pain.)
• • Associated symptoms. Nausea, vomiting, dysuria, jaundice?
• • Timing. Does it occur at any particular time?
• • Exacerbating or relieving factors. Worse with deep breathing, moving, or coughing suggests irritation of
somatic nerves either in the pleura or peritoneum; relief with hot water bottles suggests deep infl ammatory
or infi ltrative pain.
• • Surgical history. Does the pain relate to surgical interventions?
INVESTIGATION
• An investigation is a thorough search for facts, especially those that
are hidden or need to be sorted out in a complex situation.
• Search for the etiology of the disease of lesion.
1- blood investigation:-
A-hematology
B-biochemistry
C-renal function test
D-liver function test
E-cardiac enzymes
F-serological test
G-hormonal test
H-immunology
I-molecular and genetic
J-tumor markers
K-tests for infective disease
2- IMAGINING
A-XRAY
B-ULTRASOUND
C-CTSCAN
D-MRI
E-PET SCAN
3-BIOPSY
A-FINE NEEDLE ASPIRATION CYTOLOGY
B-TRUCUT BIOPSY
C-INSCIONAL BIOPSY
D-EXSCIONAL BIOPSY
MRI
PET SCAN