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History and Examination a forgotten art David J. O’Regan Visiting Professor Imperial College, LondonSERVICE✓ Please look the part ✓ Do not make a judgement ✓ Do not assume ✓ It is what matters to the patient#hellomynameis This Photo by Unknown Author is licensed under CC BY-SA Patient must be comfortable • Interpreter • Chaperone • Power distance • Power height • Power dress • Room must look and feel warm and fresh • Private - curtainsTick Box Clerking In your own words tell me what is the problem? • Look for non-verbals • Listen • Do NOT interruptPresenting complaint • When? • Progression? • Frequency? • Deterioration? • Exacerbation? • Relieving factors?• Visceral can be very vague • Somatic located one spot • Skeletal above and below the joint • Head look and listen • Very few pains bring tears to the eyes! • Beware the SILENT • Do NOT dismiss the ‘persistent’ Risks • Smoking • Alcohol • Drugs • Family history • Profession • Environment • Sun • DustPMH – Hospitalisations J, Rf, TB, Ep, Stroke PSH - Anaesthetic Key holeSystems Enquiry Open questions Systems Enquiry use plain language • CVS – how far can you walk? » How many pillows? » Any discomfort chest or legs • RS – how is your breathing? » Cough, Wheeze, Sputum or blood (colour and amount?) • Upper GI – any problems eating? Weight? » Nausea, vomiting, difficulty swallowing or indigestion? • Bowels – any problems with you bowels? » Change, colour, shape, blood or mucus? • Urine – any problems passing urine? (water)? » Flow, hesitancy, urgency, blood or stinging? – Periods – any problems? – Post menopausal – any problems with front passage? • CNS – any usual headaches, visual or hearing disturbances? • MS – any problems with mobility? » Pins and needles, loss sensation, aches, muscle weakness twitching?Drugs – look them up! Allergies please describe the reaction Social history there is pleasure, memories and satisfaction in lives Examination Patient must feel comfortable Correct Position You must feel comfortable You must be confident Rules • WASH HANDS and stethoscope • Inspection - LOOK! • Ask before you MOVE! • Palpation - Soft TOUCH and LOOK at patient • Percussion - clinical ultrasound • Auscultation - LISTEN Know your anatomy • Bony land marks • Sagittal planes – C6 – Transpyloric – Umbilical • Lymph nodes – head and neck, – arm pits, groins General • Use all your senses • Watch them walk in – frail? • Shake them by the hand • Well or unwell? • Normal or abnormal • Compare with the other side? • Compare with your own? • Colour? • Temperature? Minimum BP Foot 120 Wrist 100 Brachial 80 Femoral 60 Carotid 40 + -57 Male Hodgkin's Lymphoma diagnosed from node biopsy neck 20 years ago Treatment included splenectomy Mantle radiotherapy to chest Complication bronchiectasis Chest drains Restricted lung function Repeated infections1/3 abdomen above costal margin 1/3 abdomen in pelvis – internal 1/3 can be felt Breathing moves the viscera over the still hand Meatus TesticleSymmetry Discharge Discolouration LumpsFull name Date of Birth NHS Number Legible Black Full date Time 24 hour clock Sign Print Status GMC number On every page And please file Consent Risks versus Benefits Fears Benefits lack of access Improved well being lack of time Longer life lack of knowledge Removal of symptoms lack of control Worth to the More energy Outcome and lack of privacy Reassurance patient alone probabilities • Family • Science • Situation • Evidence Patient Surgeon • Beliefs • Experience • Evidence • Do nothing • Uncertainty • Time is a tool Risks Risks Loss of life Increased mortality Loss of function Litigation MRSA Complaint Stress Low dread High dread High • death • stroke unknown Fright Factor Low • infection• MRSA unknown • bleeding • organ failure Risk AversiveHave fun meeting new people and enjoy Learn what is normal and practice! www.heart2health.co.uk @David_ukan @BBASS_skills