History Taking

General sheet / Information Gathering

Hello Mr. …. Sit down please. I am …(position)…

Personal history Name – Age – Occupation

Complaint PainSwelling / Ulcer – Dysfunction – Others

History of present complaint Analysis

Other symptoms Relation to the main complaint

What is the problem? ….

Tell me more about that.

Tell me more about ….  What about ….?  Do you have ….?

History of present investigations and treatment

 

Systematic direct questions

I’m now going to ask you a series of questions about common medical problems.

This to make sure we do not mess anything that may be important.

  • CVS

Do you have any trouble with your heart, chest pain or palpitation?

  • Respiratory

Do you have any trouble with your lungs, shortness of breath, coughing or sputum?

  • GIT

Do you have problem in digestion, lose weight, difficulty in swallowing, heart burn, nausea/vomiting, abdominal pain, swelling, change of bowel habits, rectal bleeding?

  • Genitourinary

Do you have any problems passing urine, change of color, pain, smell?

  • Diabetes Mellitus
  • Female

Do you have problems in menstruation?

Past history

Have you been admitted to any hospital before?

Did you have any operation before?

Do you have children? How many? How old is the youngest? (Female)

Do you take any medication or contraceptive pills (Female)?

Do you have any allergy?

Family history

Do you have any similar problem in your family (children, parents, brothers, sisters)?

Does anyone of your family have a heart disease, DM, blood pressure, tumor or any chronic disease?

Social history

Do you smoke? That do you smoke? How much? For how long?

Do you drink? How much/week?

Patient concern 

Are you concerned about anything?

Summery 

To summarise …. (+ve. findings)

Ulcer – History

Ulcer Analysis

  • Site (where is it?)
  • Onset (sudden or gradual?)
  • Course (does it increase or decrease in size with the time?)
  • Duration (when did it appears?)
  • Other swellings (do you have other swellings?)
  • Relation to other symptoms like pain or swellings
  • Possible Cause(why do you think you’ve got it?)
  • Constitutional symptoms (did you become feverish?)

Swelling – History

Swelling analysis

  • Site (where is it?)
  • Onset (sudden or gradual?)
  • Course (does it increase or decrease in size with the time?)
  • Duration (when did it appears?)
  • Other swellings (do you have other swellings?)
  • Relation to other symptoms like pain (is it painful?)
  • Possible Cause (why do you think you’ve got it?)

Pain – History

Pain analysis

  • Site & referral (where is it? Where it goes?)
  • Onset (sudden or gradual?)
  • Course (how often does it happen?)
  • Duration (when did it start?)
  • Severity (how bad is it?)
  • Character (Burning, throbbing, stabbing, constricting, tightness, colicky or just a pain) (what does it feel like?)
  • Relieving factors (what eases it?)
  • Exacerbating factors (what brings it?)
  • Cause like trauma (why do you think you’ve got it?)

Lymphatic Disorders

 

Lymphadenopathy

Inspection

Number Multiple
Site
Shape
Size
Surface
Skin and color Inflammatory signs Acute lymphadenitis
Infiltrative signs Advanced malignancy
Sinus TB
Special signs Transmitted pulsations Para-aortic LN
Move with deglutition Para-tracheal LN

Palpation

Relations to the surroundings

Mobility

Relation to skin
Relation to muscles
Relation to nerves
Relation to arteries
Relation to veins
Other swellings Generalized lymphadenopathy
Temperature
Tenderness
Edge Well defined Scattered

Discrete

Ill defined Matted

Amalgamated

Reducibility
Solid, fluid or gas

Consistence

Fluctuation

Hard Advanced lymphoma
Firm TB

Chronic lymphadenitis

Cystic Cold abscess
Percussion Sternum for  :  Mediastinal masses

Tenderness in leukaemia

Auscultation Despine sign in case of mediastinal lymph nodes
After examination we will be able to answer these questions
  • Anatomical diagnosis
  • Localized or generalized
  • Aetipathologicaly (Infective, Neoplastic, Others )
  • Functional ( Pressure manifestations, Metastasis )

Lymphedema (Lower limb)

Inspection

  1. Grossly swollen legs
  2. Preserved skin creases
  3. Buffalo hump (dorsum of the foot) 
  4. Square toes

Palpation

  1. Non pitting edema
  2. Inguinal lymph nodes

TAKING HISTORY FROM A PATIENT WITH A LYMPHADENOPATHY

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Lumps (lymphadenopathy)
  • Pressure symptoms (according to the site of lymphadenopathy)
    • Neck lymphadenopathy
Dyspnea Trachea or larynx
Dysphagia Oesophagus
Hoarseness Recurrent laryngeal nerve
Horner’s syndrome Sympathetic chain
Fainting attacks Carotid artery compression
Face oedema IJV compression
  • Abdominal lymphadenopathy
Abdominal pain
Jaundice Nodes in porta hepatis
Leg edema Compression of iliac veins or IVC by iliac or para-aortic LN
Renal pain Ureteric compression
  • Chest lymphadenopathy

Chest pain

Cough

Dyspnea

  • Axillary lymphadenopathy
  • Oedema of the affected limb
Vein compression
  • Tingling
  • Numbness
Nerve compression
  • Ischemia
  • Gangrene
Artery compression
TAKING HISTORY FROM A PATIENT WITH A LYMPHEDEMA

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Swollen limb (lymphoedema)
  • Pain
  • Fever
Hectic abscess formation
Night fever TB
Pel Ebstien fever Hodgkin’s lymphoma
  • History suggesting the cause
    • If localized lymphadenopathy
      • Ask about the drainage area for (Infection – Malignancy)
    • If generalized lymphadenopathy
      • TB manifestations (Night sweat – Night fever – Loss of weight – Loss of appetite)
      • Leukaemia manifestations (Bleeding tendency – Bone aches)
      • Lymphoma manifestation (Pruritus – metastasis manifestation)
    • Secondary lymphoedema
      • Post-traumatic
        • Injuries as circumferential scars of the limbs
        • Operations as block dissection of regional lymph nodes
        • Burns at the site of lymph nodes
        • Irradiation of regional lymph nodes
      • Post-inflammatory
        • Non-specific infection
          • Recurrent non-specific lymphangitis
          • Recurrent cellulitis due to evident focus of infection
            • Interdigital infection
            • Chronic leg ulcer
          • Post-erysipelas lymphoedema
        • Specific infection (Filarial – TB)
      • Neoplastic
Differential diagnosis of swollen lower limb (lymphoedema)
  • Edema
    • Local causes
      • Venous (DVT – 1ry varicose veins – 2ry varicose veins)
      • Lymphatic obstruction) (Post traumatic – Post inflammatory – Neoplastic – Primary)
      • Arterial (Arterio-venous fistula – Post-revascularization)
      • Traumatic
      • Inflammatory
    • General causes
      • Cardiac – Hepatic – Renal – Nutritional – Allergic – Hypoalbuminaemia (Hepatic – Renal – Nutritional – Bowel – Trauma to thoracic duct)
  • Not edema
    • Local gigantism – Hemi hypertrophy – Tumor – Lipidaema in females (Cyclic – Non cyclic)
Types of primary lymphoedema

Congenita

Praecox

Tarda

Incidence 10% 80% 10%
Age At or within 1 year of birth Usually adolescence After 35 years
Sex M>F F>M M=F
Site Commonly bilateral and involve the whole leg Commonly unilateral and below the knee Usually unilateral

Chronic Venous Insufficiency and Venous Ulcers

 

Chronic Venous Insufficiency

Pigmentation (lipodermatosclerosis ulcer)

LEGS

  1. Lipodermatosclerosis
  2. Eczema
  3. Gaps (ulcers) causing white patches “atrophie blanche”
  4. Swelling (edema not in the dorsum of the foot due to subfascial fobrosis)

Venous Ulcer

Number  inspection Palpation

As inspection

LNs

Base

Mobility

Induration

lipodermatosclerosis

Extent

Tenderness

Site Gaiter or ulcer bearing area

Medial and lateral maleolai

Shape Rounded or any
Size Usually superficial
Floor Granulation tissue
Margin Pigmentation
Edge Sloping
Discharge Color – Amount – odor

Varicose Veins

 

Varicose Veins

Aim of examination

  1. The anatomical distribution of the veins
  2. Type primary or secondary
  3. Competence of saphenofemoral junction and other communicating veins
  4. Condition of deep system
  5. Presence of complication

Inspection

  1. Site and size of varicosities including Saphena varix
  2. Skin changes, ulcers and scars
  3. Swelling of the ankle

Palpation

  1. State of skin and subcutaneous tissue
  2. Sites of fascia defects
  3. Site of incompetence (Trendelenburg test + cough impulse)

Percussion 

  1. Tape test (Chevrier’s tape sign)
  2. palpation of the varicosities and pulse

Complete by Auscultation

  1. Spheno-femoral incompetence by hand-held Doppler
  2. If any bruit
  3. Examine the abdomen

History Taking for a patient with Varicose Veins

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Cosmetic disfigurement
  • Pain (Discomfort, restless leg – Dull, heavy, bursting with sense of hotness – At end of the day – On prolonged standing – Relieved by elevating the limb)
  • Night cramps
  • Vermiculation
  • Symptoms of complication
    • Haemorrhage – Thrombophlebitis – Oedema – Skin pigmentation – Atrophie blanche – Varicose eczema – Lipodermatosclerosis – Venous ulceration
  • Possible cause
  • Predisposing factors
    • Primary varicose veins
      • Female sex – High parity – Marked obesity – Constricting clothes – Estrogen intake e.g. contraceptive pills – Occupation requiring prolonged standing
    • Secondary varicose veins
      • Presence of complication – History of DVT – History of Traumatic or congenital AV fistula – History of pelvic tumors – Pregnancy