[01.11] Adult History Taking & Physical Exam_ Normal Variations V2

Technical skills, scientific knowledge, and human understanding

According to Harrison’s Principles of Internal Medicine, what three elements does a physician need in the care of the suffering?

Tact, sympathy, and understanding

What human qualities are specifically expected of a physician, beyond symptoms and signs, according to Harrison's?

Time-honored skills of healing and patient care

What do the techniques of history taking and physical examination embody?

The patient’s history and physical examination

What is the differential diagnosis primarily based on?

The patient’s story of their illness and the time course of their symptoms

What does 'history' pertain to in the context of diagnosis?

Signs of disordered anatomy and physiology

What does the 'physical examination' reveal?

All the facts of medical significance in the life of the patient

What does a complete health history include?

Feel comfortable

What is crucial for patients to offer complete information?

Observe utmost good faith

What is the physician's duty regarding patient interaction?

Trustful, sincere, and honest; attend to patients faithfully and conscientiously; secure for them all possible benefits

According to Sec. 1, Art. II, Code of Ethics, what must a physician be and do?

Give an honest medical history of his illness

What is one of the duties and obligations imposed on the patient in the physician-patient relationship?

Date and Time of History, Identifying Data, Reliability, Chief Complaint(s), Present Illness, Past History, Family History, Personal and Social History, Review of Systems

List the components of a comprehensive health history.

Can be expressed in percentages

How can 'Reliability' of patient information be expressed?

The quality of the patient’s provided information

What does 'Reliability' reflect about the patient's information?

Quote the patient’s own words but also state the appropriate medical term

What is the dual approach to recording the chief complaint(s)?

"What seems to be the problem?" or "What brings you here?"

What are example questions to ask a patient to elicit their chief complaint?

Inflections of voice, facial expressions, gestures, and attitude

What specific aspects of body language may reveal important clues regarding the patient's condition?

The main part of the history taking

What is the History of Present Illness (HPI) considered?

Complete, clear, and chronological

What kind of account should the HPI be?

Location, Quality, Quantity or severity, Timing (onset, duration, frequency), Setting, Aggravating or relieving factors, Associated manifestations

List the seven descriptions that should characterize principal symptoms in the HPI.

"Pertinent positives" and "pertinent negatives"

What two types of findings must be included in the HPI?

Spontaneously from the patient

How should data ideally flow from the patient in the HPI?

The history taker

Who is responsible for organizing the data in the HPI?

Medications

What specific information should also be stated in the HPI?

"Can you tell me how the (chief complaint) started?", "When did you first experience the pain?", "What were you doing when you first experienced the pain?", "Can you describe the quality or nature of the pain?", "Did you take any medications to relieve the pain?"

Provide examples of questions to ask when eliciting the HPI.

Childhood illnesses, Medical illnesses (with medications), Surgical illnesses, OB/gyn, Psychiatric, Immunizations

List the components of Past History.

Familial/hereditary disorders

What is the primary focus of Family History?

Hypertension, coronary artery disease (CAD), elevated cholesterol levels, stroke, diabetes, thyroid, renal disease, cancer, arthritis, tuberculosis, asthma, lung disease, headache, seizure disorder, mental illness, suicide, alcohol or drug addiction, allergies

List examples of disorders to inquire about in Family History.

Occupation, home situation, significant others, life experiences; patient’s personality and interests

What does the Personal and Social History refer to and capture about the patient?

Sexual history

What specific history is inquired about within the Personal and Social History?

Habits, practices, activities that may predispose them to certain diseases

What specific type of patient information is sought in the Personal and Social History to identify disease risk?

Cryptococcus neoformans infection from pigeon droppings

In the example provided, what infection was a patient diagnosed with due to raising pigeons?

Questions that pertain to symptoms

What kind of questions are asked in the Review of Systems (ROS)?

Start with a fairly general question

How should questions begin when addressing each system in the ROS?

Uncovers problems that the patient may have overlooked

What is a key purpose of the ROS?

Should no longer be included

If a symptom was already mentioned in the chief complaint or HPI, what should be done in the ROS?

Weight Changes (usual/recent), Weakness, Fatigability

What general symptoms are inquired about in the 'General' section of the Review of Systems?

Rashes, Lumps, Sores, Itching, Color Changes

What skin symptoms are inquired about in the 'Skin' section of the Review of Systems?

Headache, Head Injury, Dizziness

What head symptoms are inquired about in the Review of Systems?

Glasses or Contact Lenses, Pain, Redness, Tearing, Blurring of vision

What eye symptoms are inquired about in the Review of Systems?

Tinnitus, Vertigo, Earaches, Infection, Discharges

What ear symptoms are inquired about in the Review of Systems?

Frequent Colds, Nasal Stuffiness, Discharge, Itching, Hay Fever, Nosebleeds

What nose and sinus symptoms are inquired about in the Review of Systems?

Bleeding, Sores, Pain, Hoarseness

What throat and mouth symptoms are inquired about in the Review of Systems?

Swollen Glands, Goiter, Lumps, Pain, Stiffness

What neck symptoms are inquired about in the Review of Systems?

Lumps, Pain, Discomfort, Nipple Discharge, Self-examination Practices

What breast symptoms are inquired about in the Review of Systems?

Cough, Sputum, Hemoptysis, Dyspnea, Wheezing, Pleurisy, Last Chest X-ray, Asthma

What respiratory symptoms are inquired about in the Review of Systems?

Chest Pain, High BP, Palpitations, Dyspnea, Orthopnea, Paroxysmal Nocturnal Dyspnea

What cardiovascular symptoms are inquired about in the Review of Systems?

Trouble Swallowing, Heartburn, Appetite, Nausea, Bowel Habits, Pain, Bleeding, Stool Color and Size, Constipation, Diarrhea, Food Intolerance

What gastrointestinal symptoms are inquired about in the Review of Systems?

Frequency, Polyuria, Nocturia, Urgency, Burning or Pain during Urination, Flank Pain, Incontinence

What urinary symptoms are inquired about in the Review of Systems?

Reduced caliber or force of Urinary Stream, Hesitancy, Dribbling

What specific male urinary symptoms are inquired about in the Review of Systems?

Hernias, Discharges, Sores, Testicular Pain or Masses, Sexual Habits, Function, Birth Control, Condom Use

What male genital symptoms are inquired about in the Review of Systems?

Age of Menarche, Regularity, Frequency, Duration, Dysmenorrhea

What menstrual cycle symptoms are inquired about in the Review of Systems?

Age of Menopause, Post-menopausal Bleeding, Vaginal Discharge, Itching, Sores, Lumps, Birth Control Methods, Sexual habits, Dyspareunia

What menopause-related symptoms are inquired about in the Review of Systems?

Intermittent Claudication, Leg Cramps, Varicose Veins, Swelling, Color Change

What peripheral vascular symptoms are inquired about in the Review of Systems?

Muscle/Joint Pain, Stiffness, Weakness, Limitation of Motion, Timing of Symptoms, History of Trauma

What musculoskeletal symptoms are inquired about in the Review of Systems?

Nervousness, Tension, Depression, Memory Change, Suicide Attempts (if relevant), Mood Changes

What psychiatric symptoms are inquired about in the Review of Systems?

Attention or Speech, Changes in Orientation, Memory, Insight or Judgment, Headache, Dizziness, Vertigo, Loss of Consciousness, Tremors, Seizures

What neurologic symptoms are inquired about in the Review of Systems?

Anemia, Bruising or Bleeding, Transfusions

What hematologic symptoms are inquired about in the Review of Systems?

Thyroid Trouble, Heat or Cold Intolerance, Excessive Sweating, Polyuria, Weight Changes

What endocrine symptoms are inquired about in the Review of Systems?

A "conversation with a purpose"

What is the interview and health history described as?

To establish a trusting and supportive relationship; to get the information to make the right diagnosis (gathering information); to offer information

What are the three-fold purposes of the interview?

To improve the well-being of the patient

What is the primary goal of the interview?

Gathering information

As a beginning clinician, what should be the primary focus of energy during the interview?

Reduces the feeling of isolation and despair

What effect can a feeling of connectedness with the doctor and being deeply heard have on patients?

Structured framework for organizing patient information

What is a health history described as?

For all new patients, regardless of setting

When is a Comprehensive Health History typically used?

For other patients who seek care for specific complaints, urgent care, or follow-up visits

When is a Problem-Oriented History typically used?

More fluid; demands effective communication and relational skills

What is the interviewing process described as, in contrast to the health history format?

Appears calm and unhurried; avoids reactions that belittle the patient; shows cleanliness and neatness; adjusts the environment; is discrete in taking notes

What are characteristics of a skilled interviewer's clinical behavior and appearance?

Jots down short phrases, specific dates and words

What kind of notes should a skilled interviewer jot down?

Greeting the patient and establishing rapport

What is the first step in the sequence of the interview?

Lay the foundation for your relationship

What do the initial moments of the encounter do?

By name and introduce yourself

How should you greet the patient?

A formal title (e.g., "sir" or "ma’am")

How is it recommended to formally address patients, especially among Filipinos?

Acknowledge visitors

What should be done if visitors are present during the interview?

Ask patient’s permission

What must be done before conducting the interview in front of visitors due to confidentiality?

Always be attuned to the patient’s comfort

What is a key principle when establishing rapport?

"How the patient is feeling" and "if you are coming at a convenient time"

What questions can be asked to assess the patient's comfort and convenience?

Give your undivided attention

What is crucial for establishing rapport?

Pursue the patient’s reason for seeking healthcare (chief complaint/s)

What is the objective when inviting the patient’s story?

"Open-ended" questions

What type of questions should be primarily used to invite the patient's story?

"What concerns bring you here today?", "What made you decide to come in to see me today?", "What’s the problem, Mr. A, what brought you here?"

Provide examples of open-ended questions to invite a patient's story.

Pursue the seven attributes of pain and other symptoms

What is the goal when expanding and clarifying the patient's story?

OLD CARTs or OPQRST

What mnemonics are used to remember the seven attributes of pain or symptoms?

Onset, Location, Duration, Character, Aggravating/Alleviating Factors, Radiation, Timing

What do the letters in OLD CARTs stand for?

Onset, Palliating/Provoking Factors, Quality, Radiation, Site, Timing

What do the letters in OPQRST stand for?

Understandable and appropriate language; avoid highly medical terms

What kind of language should be used when clarifying?

"Heart attack" or "inatake po kayo sa puso"

What lay terms should be used instead of "myocardial infarction"?

The patient’s “own words”

Whose words should be used when clarifying symptoms to avoid confusion?

Confuses the patient and blocks communication

What effect does technical language have on patients and communication?

Moving back and forth from open-ended to increasingly focused questions

How should the time and course of symptoms be established?

Start to entertain various differential diagnostics

What process begins as you speak with the patient regarding potential diagnoses?

Test your hypothesis by asking questions that pertain to the suspected condition

How do you generate and test diagnostic hypotheses, for example, if you suspect a UTI?

Share it with the patient so both of you have a shared understanding

What should be done once the diagnosis is narrowed down?

Further evaluation, treatment, and patient education

What does negotiating a plan include?

"Let’s first focus on the main problem and discuss the ones that can wait later on."

What is an example phrase to use when planning for follow-up and closing the interview, especially when time is limited?

Sexual history, Mental health history, Alcohol and illicit drug use, Family violence, Death and the dying patient

List examples of sensitive topics that require specific approaches.

To be non-judgmental

What is the single most important rule when broaching sensitive topics?

Explain why you need to know certain information

What should always be done before discussing sensitive topics, even if uncomfortable?

Find opening questions

What technique should be employed to begin sensitive topic discussions?