Undergraduate Medicine Study Guide

History Taking
Frameworks for consultation
 4 tasks for consultation:
 Management of presenting problems
 Modification of help-seeking behaviour (did they come too soon/too late)
 Management of continuing problems
 Opportunistic health promotion
 Objective: integration of:
 Doctor‟s agenda: Correct diagnosis, preventative health care
 Patient‟s agenda: expectations, feelings, fears, understanding of illness experience
 Silverman and Kurtz: - five phases of the consultation:
 Initiating the session: introduce yourself, why are you here, how can I help (not how are you)
 Gathering information: start with open questions, physical exam
 Building the relationship
 Explanation and planning: what you‟ll do, what you want the patient to do. Involve patient in
planning. Give them as many choices as possible
 Closing the session: any more questions, check understanding, follow up, emergencies, etc
 Double Diamond model:
 First phase: patient presents problems, doctor hones down
 Second phase: diagnosis reached, expansive phase of explanation, management options, then
brought to closure
 FIFE: Feelings, Ideas, Function/Dysfunction, Expectations
 Remember: listen, reassure
History Taking
 Always ask why they‟ve come: and why that is a concern to them (what are they scared of?)
 Key skills:
 Establishing rapport
 Asking questions in a logical order
 Observing non-verbal queues
 Proper interpretation
 Record positive & negative findings. Always amplify positive findings:
 Time course
 How quickly did it come on (what were you doing then), pattern since then
 Site and radiation
 Character
 Severity
 Aggravating or relieving factors
 Associated symptoms
 Previous occurrences
 For each potential cause of a symptom think of:
 Detail of the symptom
 Other symptoms you would expect if that cause
 Ask about risk factors of that cause
 See also Talking with Children, page 567 and Talking with Adolescents, page 665
History Outline
 History:
 Identifying data
 Presenting complaint (or complaints) eg Cough with green sputum 2 days, Dizziness 4 weeks
 History of presenting complaint
 Drug and medication use, including allergies, OTC drugs, herbal/alternative medicines
 Past medical and surgical history (including hospital admissions)
 Screen for hypertension, heart disease, asthma, diabetes, epilepsy, rheumatic fever, TB, bleeding
tendency, hepatitis B
 Family history of illness (if genetic illness draw family tree)


4 4th and 5th Year Notes

,  Social history: smoking, alcohol, job, living situation, social supports, overseas travel, functional
history in the elderly or disabled
 If a child, then obstetric, neonatal, growth and development, immunisations
 Review of systems
 At end of history always ask „is there anything else you want to tell me‟
 Note mental function and communication: dementia/delirium common
 Physical Exam:
 Vital signs: temperature, respiratory rate, pulse, blood pressure
 General observations: distress, pallor, hydration, cyanosis, weight
 Relevant systems exams
 Formulation and problem list:
 List of active problems or clusters of problems (always include smoking if they smoke)
 List of inactive problems or clusters of problems
 For each problem, list a set of differential diagnoses, investigations to establish which it is,
immediate management, other management strategies
 Progress notes:
 Changes in symptoms
 Changes in physical exam or investigation
 Assessment of what this means
 Plan for what to do now

Examination
Purpose of Examination
 Aims to:
 Confirm suspicion
 Exclude other causes that mimic it
 Measure severity
General
 Are the conditions OK to do an exam? Is the light in the room OK, is the patient positioned and
exposed, etc
 ALWAYS OBSERVE FIRST: stand back and look.
 Distress, comfort, central or peripheral cyanosis, pallor, jaundice, dehydration, SOB, how sick or well
 Cachectic = severe loss of weight and muscle wasting. Usually malignancy, but also severe cardiac
disease (due to anorexia from liver congestion and impaired absorption due to intestinal venous
congestion)
 Facies: features of the face suggesting diagnoses: eg acromegaly, Cushing‟s, Down‟s, myxoedema,
Parkinson‟s, hair distribution in men and women, etc
 Weight, body habitus and posture, including deformities
 Include vital signs in general assessment: pulse, blood pressure, temperature, respiratory rate
Fever
 See also Fever in Children, page 616
 Taking a temperature:
 Serial measurements the most useful
 Also take pulse – if temp should have heart rate (except in typhoid)

Normal Values Low High
Oral 36.6 37.2
In hot weather +0.5 +0.5
Rectal +0.2 +0.5
Axillary -0.5 -0.5

 Children. The most common emergency presentation in paediatrics. Most common cause is viral
infection, otitis media, pharyngitis, and tonsillitis. Also consider bladder infection, Rheumatic fever,
Meningitis. Kids spike temperature easily. Febrile convulsions occur between 18 months and 5 years.
At other ages investigate other causes



Patient Management 5

, Types of fever:
 Continued: does not remit e.g. typhoid, drug fever
 Intermittent: falls to normal each day – pyogenic infections, lymphomas
 Relapsing: returns to normal for days then rises again – Malaria, lymphoma, pyogenic
Pyrexia/Fever of Unknown Origin (PYO/FUO)
 See also:
 Pyrexia of unknown origin if returning from 3rd world, page 511
 Fever in a Neutropenic Patient, page 301
 Formal definition: > 38 C, > 3 weeks, no known cause (ie normal admission tests already done).
However, often used to describe a temperature that that you haven‟t done any tests on yet
 Usually an unusual presentation of a common disease
 History, exam, investigations, time course, urgency and likely cause depend on setting:
 Community acquired (Classic PUO)
 Nosocomial PUO (ie hospital acquired)
 Immune-deficit or HIV related PUO
 Differential:
 Neoplasm: lymphoma, leukaemia (check lymph nodes), other (hepatic, renal, other)
 Infection:
 Bacterial: Tb, abscess (subphrenic, hepatic, pelvic, renal – look for  neutrophils),
endocarditis (any dental work?), pericarditis, osteomyelitis, cholangitis, pyelonephritis, PID,
syphilis, cystitis
 Viral: EBV, CMV, HBV, HCV, HIV, Varicella-Zoster
 Parasitic: malaria, toxoplasmosis
 Fungal
 Connective Tissue: RA, SLE, Vasculitis (eg polyarteritis nordosa – check for Raynaud‟s
phenomena – abnormal response in fingers to cold)
 Miscellaneous: drug fever (especially penicillins, sulphonamides), Rheumatic fever, inflammatory
bowel disease, granulomatous disease (eg Sarcoid), Fictitious/Munchausen‟s (eg injecting
themselves with saliva)
 Clues:
 Weight loss  chronic
 Check eyes: iritis in connective tissue disease, jaundice, etc
 Check tonsils, glands, ears for infection
 History:
 Travel (eg malaria, did they have prophylaxis)
 Exposure to others
 Sexual history
 Weight loss
 Been to other doctors (had any antibiotics)
 Occupational exposure (eg cows)
 Exam:
 Lymph nodes
 Heart murmurs
 Skin for rashes
 Abdominal exam
 Possible investigations:
 Blood count
 Blood cultures
 Urine microscopy & culture
 Liver function (eg hepatitis)
 Viral serology
 Malaria film
 Chest X-ray
Tiredness
 Differential:
 Sleep disturbance: eg anxiety, sleep apnoea, narcolepsy,



6 4th and 5th Year Notes

,  Depression
 Anaemia
 Endocrine: hypothyroidism, hypocortisol (Addison‟s), diabetes, hypercalcaemia (due to PTH)
 Infection (eg EBV)
 Cancer
 Drugs: alcohol intoxication, sedative drugs,
 Head injury (eg subdural haematoma)
 Post ictal states
 Hypoglycaemia
 Hepatic encephalopathy, Wernicke‟s encephalopathy
 Chronic heart failure
 Malabsorption (eg coeliac disease)
 Pregnancy
 See also Sleepiness, page 90
Oedema
 Include in exam of appropriate system
 Need to retain 3 – 4 litres before pitting begins
 Exam:
 Where is it? Distribution
 Is it pitting
 Other signs of inflammation
 Mechanisms:
 ↓colloid osmotic pressure
 ↑hydrostatic pressure
 ↓permeability of wall
 Localised Cause:
 Inflammatory (e.g. infection, allergy - cytokine mediated)  pain/heat/redness/swelling
 Trauma
 Venous occlusion by tumour or lymph nodes
 Thrombis (e.g. DVT)
 Generalised Cause:
 Is it bilateral? Usually worse in the evenings
 Heart Failure:
 Mechanism: ↑preload  ↑venous pressure, ↓renal perfusion  ↑renin  ↑Na/H20
 History: check SOB, orthopnea, PND
 Signs/Tests: CXR, ECG, Echo
 Liver:
 Mechanism: liver failure/malnutrition  ↓colloid pressure  ↓renal flow  ↑retention
 History: check alcohol, cholestasis, hepatitis, bleeding, bruising
 Signs/Tests: portal hypertension, enlarged liver, jaundice, bloods (Liver Function, INR)
 Renal:
 Mechanism: nephrotic syndrome  ↓colloid pressure (have to loose 3.5 g protein a day to be
nephrotic. NB nephritis is inflammation)
 History: check change in urination, nocturia (due to diuresis), diabetes
 Signs/tests: ↑BP, urine test, 24 hr urine, dipstick, urea/creatinine
 Drugs (eg vasodilators, like calcium channel blockers) can cause ankle oedema
 Gastrointestinal: Malabsorption  hypoalbuminaemia
 Non-pitting lower limb oedema
 Lymphoedema (eg malignant invasion of lymphatics, allergy) doesn‟t pit – push for 10 seconds
 Hypothyroidism
Hands
 Nails:
 Takes ~ 6 months for fingernails to grow out
 Clubbing:
 Respiratory: carcinoma, fibrosis, cystic fibrosis, TB, chronic suppuration (eg bronchiectasis),
idiopathic pulmonary fibrosis, NOT asthma or CORD alone


Patient Management 7