INTRODUCTION

Accurate diagnosis relies firmly on the

foundation of accurate and inclusive
history and competently performed
physical examination.
Professional obligations
• The care of your patient is your first concern
• Protect and promote the health of patients and the
public
• Provide a good standard of practice and care

◦ Keep your professional knowledge and skills up to

date
◦ Recognize and work within the limits of your
competence
◦ Work with colleagues to serve your patients' interests
best
Professional obligations
Treat patients as individuals and respect
their dignity, confidentiality
Work in partnership with the patient
◦ Listen to your patients and respond to their
concerns and preferences
◦ Give information in a way they can understand
◦ Respect their right to reach decisions with you
about their care
◦ Support patients in caring for themselves to
improve and maintain their health
Professional obligations
Be honest and open, and act with integrity
◦ Act without delay if you have a good reason to
believe that you or a colleague may be putting
patients at risk
◦ Never discriminate unfairly against patients or
colleagues
◦ Never abuse your patient's or the public's trust
in you or the profession
 Confidentiality and Respect
The qualities that patients look for in a doctor
Humaneness
Competence
Accuracy
Honesty
Openness
Responsiveness
Involving the patient in the decision-making process
Trustworthiness
Time to listen
 PERSONAL RESPONSIBILTY
Take care of your health- get immunized
against infectious diseases like Hepatitis B
HAND WASHING and CLEANLINESS
Avoid improper emotional relationship with a
patient
Do not express your personal beliefs- political,
religious or moral ones, to your patients
Appropriate, Smart, Sensitive and Modest
dress Sense
 COMMUNICATION SKILLS
Good communication skills are the most important part of
being a good doctor. These include:
 maintaining good eye contact
checking the patient's prior knowledge or understanding
active listening
encouraging verbal and non-verbal communication
avoiding jargon
eliciting and addressing the patient's agenda
ability to discuss difficult issues
going at a pace that is comfortable for the patient
HISTORY TAKING
Setting the scene
Pleasant environment- clean, quiet, private
to ensure confidentiality, avoid
interruptions(phone)
Greet with a smile
Introduce yourself- trainee, qualified
Establish a rapport
Eye contact
Show empathy, concern
Observe non-verbal cues from the patient
FORMAT OF HISTORY TAKING
Patients demographics
Presenting complaints
History of presenting complains
Past medical history
Obstetric and gynaecological history
Family and social history
Drug and allergy history
Systemic inquiry
Summary of key findings in the history
1. Patients demographics
Name
Age
Sex
Address
Phone number
Next of Kin
Occupation
Marital status
Date of entry and hospital number
Informant
2. Presenting complaints
What are the chief complaints?
What is the duration of complains?
Record in chronological order.
Example:
Cough for one month
Hotness of body for three weeks
Bloody sputum for one week
Inability to walk for 2 days.
3. History of presenting complaints
Progression of illness and evolution over time
Aggravating factors
Relieving factors
Other associated factors
Do a thorough inquiry pertaining to that
system or illness
Significant positive and negative data that
might give clues useful in differential
diagnosis
3. History of presenting illness
Example:
List of clarifications for a complaint of pain
Site
Radiation
Character
Severity
Time course
Aggravating factors
Relieving factors
Associated symptoms
4. Past medical history
Previous hospitalizations- Illness/diagnoses
dates and treatment, significant complications
 Medications used- prescribed or over the counter, herbal
or alternative therapy
Trauma
Surgery
Operations
Childhood illnesses
5.Obstetric and Gynaecological history
Gynaecological history
Menarche- Age at which periods began
Last menstrual period- when, length of
period, amount of bleeding, regularity of
periods, pain on menstruation
Erratic bleeding
Contraception- type, how long , side effects
Pain on coitus
Abnormal vaginal discharge
Obstetric history
Pregnancies
Number of births
Mode of delivery
Illnesses during pregnancies
Miscarriages or abortions
Complications during pregnancies
6. Family and social history
Father
Mother
Each sibling
History of disease in which heredity or
contact may play a role
Record a family tree- up to third
generation if suspecting hereditary disease
Social history
Marital status, age and health of spouse, ages
and number of children. Previous marriages
Residence- type of house, owned or rented
rooms, toilets, water, heating, cooking,
neighbors
Education level
Occupation/employment- current, previous,
exposure to hazards, income, debt, travels
Habits- use of alcohol, tobacco(type, how
many packs and years), exercise, sexual habits
7. Drug and allergy history
Drugs
Medicines – duration, dosage, for what
illness
Drug abuse- type, duration, dosage,
effects, elicit addition feature
Allergies:
Asthma, hives, food, skin, drugs, hay
fever
8.Systemic inquiry
Direct questions about bodily systems not covered by the
presenting complaint
1. Cardiorespiratory
Chest pain
Intermittent claudication
Palpitation
Ankle swelling
Orthopnoea
Nocturnal dyspnoea
Shortness of breath
Cough with or without sputum
Haemoptysis
Example of systemic inquiry
2. Gastrointestinal
Abdominal pain
Dyspepsia
Dysphagia
Nausea and/or vomiting
Change in appetite
Weight loss or gain
Bowel pattern and any change
Rectal bleeding
Jaundice
3.Genitourinary
Haematuria
Nocturia
Frequency
Dysuria
Menstrual irregularity - women
Urethral discharge - men
4. Neurological Seizures
Collapse or blackouts
Dizziness and loss of balance
Vision
Hearing
Transient loss of function (vision, speech, sight)
Paraesthesiae
Weakness
Wasting
Spasms and involuntary movements
Pain in limbs and back
Headache
5.Locomotor
Joint pain
Change in mobility
Summary
Briefly summarize what the patient has
told you
Reflect this back to the patient. This
allows the patient to:
◦ Correct anything you have misunderstood
◦ Add anything that may have been forgotten
Tellthe patient what you are going to
examine and gain his permission to do so.
Questions?
CORE TEXTBOOKS
1. Michael Swash, Michael Glynn(2007):
Hutchison's Clinical Methods: An Integrated
Approach to clinical Practice; Saunders
limited; 22nd Edition

2. Graham Douglas, Fiona Nicol, Colin

Robertson (2009): MacLeod's Clinical
Examination: Livingstone; 12th Edition

3. St. Johns First Aid Manual