bds y3 hitory & introduction to medicine16!08!2011

8/2/2019 BDS Y3 Hitory & Introduction to Medicine16!08!2011

http://slidepdf.com/reader/full/bds-y3-hitory-introduction-to-medicine16082011 1/36

INTRODUCTION TO MEDICINE

AND HISTORY TAKING

DR.NAN NITRA THAN

M.B.,B.S,DTM&H,M.C.T.M (TROPICAL MEDICINE)

LECTURER,MEDICINE UNIT,FOM



LEARNING OBJECTIVES

• Recognise the symptoms and signs of various medical illnesses infully clothed patients

• Develop clinical acumen to recognize clinical features, including

dyspnoea, cyanosis, jaundice, pallor, general non-well being,cachexia,etc.

• Refer to the patient’s medical history and be aware of theimportance of common medical disorders in clinical dentistry,

particularly diabetes mellitus, hypertension, jaundice,epilepsy, hepatitis and other liver disorders, renal disorders, bleeingdisorders, chronic heart disease, rheumatic heart disease,

infective endocarditis,congenital heart disease,pneumonias,anaemia,

stroke, cranial nerve palsies and common tropical infections.



MEDICINE LECTURES

Module 1 to 4 (* with tutorial classes *)

• CVS

• RS

• GIT

• Liver and biliary tract& pancreatic disorders

• Bleeding and clotting disorders• Anaemia and haemopoietic disorders

• Skeletal and joint disorders

• Connective tissue disease

• Common metabolic disorders

• Diabetes mellitus• CNS

• Peripheral nervous system disorders and neuromuscular disorders

• Skin disorders and drug induced muco cutaneous disorders

• Shock and resuscitation

• Myeloproliferative and lymphoproliferative diorders



Clinical teaching (Clinical Skill Centre)

Module 1 to 4• CSC 1 Basic history taking in medicine

• CSC 2 Basic physical examination in medicine 1

• CSC 3 Basic physical examination in medicine 2• CSC 4 Examination of cranial nerves

V,VII,IX,XI,XII(1)

• CSC 5 Examination of cranial nervesV,VII,IX,XI,XII(2)

Hospital visits (4)

Common medical illness



HISTORY TAKING



INTRODUCTION

Aim:

– At the end of the session students should know fundamentals of history taking and take a history of a simple disease

Objectives:At the end of the session students should record:

– Chief complaint

– Present illness

– Past medical history

– Systemic enquiry – Family history

– Drug history

– Social history



• Have a system based approach

• Be focused

• Practice makes you perfect

• BLISS: Beginning, Listening,

Information gathering, Sharing

information, Setting goals.

STEPS



• Identify and Greet the patient

• Introduce yourself

• Understand the mood of the patient

• Be sensitive to the patient’s privacy and

dignity

• Make him comfortable while taking

history

GENERAL APPROACH



COMMUNICATING WITH PATIENT

• Speak clearly and audibly

• Listen keenly with patience• Do not jargon

• Do not use medical terms

• Avoid leading and direct questions

• Do not interrupt the patient



TAKING THE HISTORY

AND RECORDING

Always record personal details:

– Name,

– Age,

– Sex,

– Address,

– Ethnicity,

– Occupation,

– Religion,

– Marital status.

– Record date of examination



ELEMENTS

• Presenting complaint

• History of presenting complaint

• Past medical history and risk factors

• Drug history and allergies

• Family history

• Social history

• Systemic or other system enquiry



PRESENTING COMPLAINTS

• Main reason to push the patient seeking a physician’sconsultation

• Short/specific in one clear sentence communicating

present/major problem/issue

• Record the problem in the patient’s own words

• Mention the duration of the illness

• Arrange the complaints in a chronological order interms of duration

Note: CC should be ut in atient lan ua e E . Chest ain for one month duration



PRESENTING COMPLAINTS IN CVS

& RS

• Chest pain (angina)

• Shortness of breath ( Dyspnoea)

• Giddiness (Syncope)• Feel the heart beat or tap (Palpitation)

• Ankle swelling (Pedal edema)

• Cough• Claudication pain

• Fatiguability



PRESENTING COMPLAINTS IN GIT

• Abdominal pain : constant or colicky / sharp ordull/ site / radiation/duration/onset/severity/relation tofood

• Swallowing difficulty

• Indigestion

• Nausea vomitting

• Bowel habit : constipation/diarrhea

• Tenesmus or urgency



PRESENTING COMPLAINTS IN GUT

• Incontinence• Painful micturition

• Haematuria (bloody micturation)

• Nocturia (Needing to micturate at night)

• Frequency ( frequent micturition)

• Polyuria( frequent passing of large volume of urine)

• Hesitancy (difficulty starting micturition)

• Vaginal discharge: menses, frequency,regularity, heavy or light, duration, painful or not

• Number of pregnancy



PRESENTING COMPLAINTS IN NS

• Special senses: sight, hearing,smell and taste

• Seizures, faints

• Headaches

• Pins and needle( paraesthesia or numbness)

• Limb weakness

• Poor balance

• Speech problems

• Psychiatric problems



HISTORY OF PRESENT ILLNESS



• Elaborate on the chief complaint in detail

• Ask relevant associated symptoms

• Have differential diagnosis in mind• Lead the conversation and thoughts

• Decide and weight the importance of

minor complaints




• Avoid medical terminology and make use of a descriptivelanguage that is familiar to them

• Ask SOCRATES for each symptom ( Pain)

Site : somatic (sprain ankle) or viseral ( angina )

Onset: gradual or sudden

Characteristic :Sharp/dull/burning/tingling/boring/stabbing/crushing/tugging(prefer using pt’s description)

Radiation: eg. Neuronal pathway – diaghragmatic pain at theshoulder tip via the phrenic nerve

Associated symptoms(nausea , sweating)Timing: of pain / duration

Exacerbating & relieving factors :(food/activity/posture/medication)

Severity : difficult to access . May be with scale of 1 to 10


Hi f P i C l i (HPC)



Sequential presentation

•Always relay story in days before admission e.g. 1 week before the

admission, the patient fell while gardening and cut his foot with a stone.

•Narrate in details – By that evening, the foot became swollen and patient

was unable to walk. Next day patient attended hospital and they gave

him some oral antibiotics. He doesn’t know the name. There is no effect

on his condition and two days prior to admission, the foot continued toswell and started to discharge pus. There is high fever and rigors with

nausea and vomiting.

History of Presenting Complaint(HPC)

In details of symptomatic presentation

•If patient has more than one symptom, like chest pain, swollen legs

and vomiting, take each symptom individually and follow it throughfully mentioning significant negatives as well. E.g the pain was central

crushing pain radiating to left jaw while mowing the lawn. It lasted for

less than 5 minutes and was relieved by taking rest. No associated

symptoms with pain/never had this pain before/no relation with food/he

is Known smoker,diabetic & father died of heart attack at age of 45.

In details of present problem with- time of onset/ mode of evolution/ any

investigation;treatment &outcome/any associated +’ve or -’ve symptoms.



PAST MEDICAL HISTORY



• Start by asking the patient if they have any medicalproblems

• IHD/Heart Attack/DM/Asthma/HT/RHD,TB/Jaundice/Fits :E.g. if diabetic- mention time of diagnosis/current medication/clinic check up

• Past surgical/operation history

• E.g. time/place/ and what type of operation. Note anyblood transfusion and blood grouping.

• History of trauma/accidents

• E.g. time/place/ and what type of accident

Past medical history



DRUG HISTORY



Drug History

• Always use generic name or put trade

name in brackets with dosage, timing and

how long. Example: Ranitidine 150 mgBD PO

• Note: do not forget to mention

OCP/Vitamins/Traditional medicine



FAMILY HISTORY



• Any familial disease/running in families

e.g. breast cancer, IHD, DM,schizophrenia, Developmental delay,

asthma, albinism

FAMILY HISTORY



SOCIAL HISTORY



SOCIAL HISTORY

• Smoking history - amount, duration and type.

A strong risk factor for IHD

• Drinking history - amount, duration and type.

Cause cardiomyopathy, vasodilatation

• Occupation, social and education background,

family social support and financial situation



OTHER RELEVANT HISTORY

• Gyane/Obstetric history if female

• Immunization if small child

• Note: Look for the child health card• Travel and sexual history if suspected STI or infectious

disease• Note:

• If small child, obtain the history from the care giver.Make sure; talk to right care giver.

• If some one does not talk to your language, get aninterpreter(neutral not family friend or member alsofamiliar with both language). Ask simple & straightquestion but do not go for yes or no answer.



System Review (SR)This is a guide not to miss anything

Any significant finding should be moved to HPC or PMH

depending upon where you think it belongs

Do not forget to ask associated symptoms of PC with theSystem involved

When giving verbal reports, say no significant finding on

systems review to show you did it. However whenwriting up patient notes, you should record the systems

review so that the relieving doctors know what system

you covered

System Review



System Review

Respiratory System

•Cough(productive/dry)

•Sputum (colour, amount,smell)

•Haemoptysis

•Chest pain•SOB/Dyspnoea

•Tachypnoea

•Hoarseness•Wheezing

Cardiovascular•Chest pain•Paroxysmal Nocturnal Dyspnoea

•Orthopnoea•Short Of Breath(SOB)•Cough/sputum (pinkish/frank blood)

•Swelling of ankle(SOA)

•Palpitations•Cyanosis

Gastrointestinal/Alimentary•Appetite (anorexia/weight change)•Diet

•Nausea/vomiting

•Regurgitation/heart burn/flatulence•Difficulty in swallowing

•Abdominal pain/distension

•Change of bowel habit•Haematemesis, melaena,haematochagia

•Jaundice

General•Weakness

•Fatigue

•Anorexia

•Change of weight

•Fever

•Lumps•Night sweats

S t R i



System Review

Urinary System•Frequency

•Dysuria

•Urgency

•Hesitancy

•Terminal dribbling

•Nocturia

•Back/loin pain•

Incontinence•Character of urine:color/ amount (polyuria) & timing

•Fever

Nervous System•Visual/Smell/Taste/Hearing/Speechproblem

•Head ache

•Fits/Faints/Black outs/loss ofconsciousness(LOC)

•Muscleweakness/numbness/paralysis•

Abnormal sensation•Tremor

•Change of behaviour or psyche

Genital system

•Pain/ discomfort/ itching

•Discharge•Unusual bleeding•Sexual history

•Menstrual history – menarche/ LMP/ duration & amount of cycle/ Contraception

•Obstetric history – Para/

Musculoskeletal System•Pain – muscle, bone, joint

•Swelling

•Weakness/movement•Deformities

•Gait



Conclusion (SOAP)Subjective: how patient feels/thinks about him. How does

he look. Includes PC and general appearance/condition of patient

Objective – relevant points of patient complaints/vital

sings, physical examination/daily weight, fluid balance,

diet/laboratory investigation and interpretation

Plan – about management, treatment, further

investigation, follow up and rehabilitation

Assessment – address each active problem after making a

problem list. Make differential diagnosis.



Thank you

bds y3 hitory & introduction to medicine16!08!2011

Documents