Department of Medical Education

Ayub Medical College

Abbottabad

History Taking, General Physical

Examination and Vital Signs
 GROUND RULES
 Timings: 10.00 AM – 12.00 PM (No breaks)
 Two Weeks rotation: Monday to Thursday
 4 Days a week x 2 weeks: Total = 8 Days
 2 hours per day, x 8 days: Total = 16 Hours
 Attendance (Mandatory in all sessions)
 Mobile (Switch Off or Silent / Vibration mode)
 Respect each other’s opinion
 Avoid Cross Talks – Raise hands for questions
 Equality - Equal Chance to every participant
 Active and Interactive Learning
 Care of the precious Training Equipment 2
 OUTLINE OF THE SESSION
 History taking
 General Physical Examination (GPE)
 Heart Attack - OPQRST
 Stroke - FAST Assessment
 SAMPLE
 STABLE
 Video Presentation
 Practice Session
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 HISTORY TAKING
 FULL NAME:
 AGE: SEX:
 MARITAL STATUS:
 ADDRESS (POSTAL):
 PHONE NO. RESIDENCE:
CELL NUMBER:
 EMERGENCY # CONTACT:
 OCCUPATION: RELIGION:
 EDUCATION:
 DATE OF ADMISSION: OPD. NO. :
 SOURCE OF REFERRAL:
 SOCIO-ECONOMIC STATUS: 4
 HISTORY TAKING
 Presenting complaints
 History of present illness
 Birth history
 Prenatal / Neonatal
 Growth (milestones of development)
 Immunization
 Feeding history

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 HISTORY TAKING
 Previous history of illness
 General state of health
 Childhood illness
 Adult illness
 Accidents / injuries
 Operations
 Hospitalizations
 Allergies / immunization
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 MENSTRUAL HISTORY
 Age of menarche
 Cycle
 Rhythm (regular / irregular)
 Flow
 Dysmenorrhea
 Inter-menstrual bleed

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 HISTORY TAKING
 Treatment history
 Previous treatment
 Current treatment
 Family history
 Personal history
 Social and occupational history

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 SYSTEMIC REVIEW
 GENERAL - usual weight, recent weight
change, weakness, fatigue, fever
 SKIN
 HEAD
 EYES
 EARS
 NOSE AND SINUSES
 MOUTH AND THROAT
 NECK 9
 SYSTEMIC REVIEW
 BREAST
 RESPIRATORY
 CARDIAC
 GASTROINTESTINAL
 URINARY
 MUSCULOSKELETAL
 NEUROLOGIC
 HEMATOLOGIC
 ENDROCRINE
 PSYCHIATRIC 10
 VITAL Signs
ASSESSING TEMPERATURE, PULSE
AND RESPIRATION

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 TEMERATURE
Common Types of Thermometers:
 Glass thermometer (Oral and Rectal)

 Electronic thermometer (Used to take

oral and aural temperature)
Common Sites for taking temperature
 Mouth

 Ear

 Axilla

 Rectum 12
 TEMERATURE
 Take a clean thermometer
 Shake thermometer so that mercury
goes below the lowest reading
 Place it under the patient’s tongue and
instruct him/her to close both the lips
(Not to be held by teeth)
 Wait for at least 1min
 Take out thermometer and note the
mercury level on the graduated tube,
this reading indicates the temperature
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 TEMERATURE
 Normal body temperature of human
body is 98.6 F or 37 C

 Pyrexia/Fever refers to elevated body

temperature.

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 PULSE
 Seven sites where pulse may be
counted (radial, carotid, femoral,
popliteal, posterior tibial, dorsalis pedis,
Superficial Temporal)

 Describe method of assessing pulse in

infants (heart rate in neonates and
brachial pulse in infants)
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 Pulse
 Location: The radial pulse is readily felt just lateral
to the tendon of flexor carpi radialis muscle.


 Pronation: Slightly pronate the forearm.



 Fixation: Gently place three fingers (index, middle

and ring) on the radial pulse.


 Counting: Count the radial pulse for one minute, and

rate will be recorded as per minute.
 In emergency situation counting can be done for half
a minute and rate can be calculated by doubling this
figure. 16
FACTORS AFFECTING PULSE RATE
• Age
• Gender
• Activity level
• Temperature
• Anxiety
 Normal adult heart rate is 60-100 / min
 Pulse greater than 100/min is called
tachycardia,
 Pulse less than 60/ min is called
bradycardia. 17
 RESPIRATORY RATE
 Observe movements of the chest and/or
abdomen
 Count a cycle of expiration and
inspiration as one breath for one minute
 Avoid making the patient conscious
while counting respirations as he / she
may hold his / her breath
 NORMAL RATE OF RESPIRATION
• ADULT -14-16 Breaths per min
• Infants – 20-25 Breaths per min 18
 HEART
Two main Coronary arteries
• Supply Blood to the Heart muscle
• Heart Disease due to narrowing or blockage

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 HEART ATTACK
(Myocardial Infarction)
 Commonly caused by a sudden
obstruction of blood supply to part
of the heart muscle

 Clot in a Coronary artery

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 HEART ATTACK / MI
Signs & Symptoms
 Severe chest pain
 Spreading to jaw or one / both arms
 Pain not eased with rest
 Discomfort high in the abdomen may
feel like severe indigestion
 Collapse without warning

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 HEART ATTACK / MI
 Shortness of Breath
 Feeling of Impending Doom
 Ashen skin (Pallor+Hypoxia)
 Blue lips (Cyanosis)
 Profuse Sweating
 Air Hunger
 Silent Infarction may be seen in
Diabetics, Women and Elderly men
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 O.P.Q.R.S.T.A
History: Cardiac Chest Pain
 Onset – Sudden, gradual

 Provocation – Aggravated / relieved by

 Quality – Stabbing, colicky, burning

 Region / Referral / Recurrence / Relief

 Severity – On a scale of 1 (min) to 10 (max)

 Time of Onset of symptoms

 Associated Symptoms: e.g. Nausea, Vomiting

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 HEART ATTACK / MI
Treatment
 Place in Half Sitting Position
 Make casualty Comfortable
 Call an Ambulance/Doctor/Advanced Life
Support
 Medication: MONA (Morphine, Oxygen,
Nitrates, Aspirin)
 Rest & constantly Monitor
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 STROKE
Occurs when blood flow to the brain is
disrupted by a Clot or Bleeding from a
damaged blood vessel.
Warning Signs of Stroke
 Sudden numbness & Weakness of face, limbs,
on one side of the body
 Headache or Dizziness
 Sudden Confusion,
 Sudden trouble speaking / understanding
 Sudden trouble seeing in one or both eyes
 Gradual/Sudden loss of consciousness
 Drooping of one side of the face
 Paralysis down one side of body 25
 F.A.S.T. ASSESSMENT
 F – Facial Weakness
• Can patient smile or show teeth
• Have Eyes or face drooped?
 A – Arms Weakness
• Can patient raise both arms equally and
hold position for 5 seconds
 S – Speech Problems
• Can patient speak clearly and understand
what you say
 T – Even if One is Positive, its Time to
• Note onset of Symptoms, Call for help, Treat 26
 STROKE
Treatment
 Keep casualty comfortable
 Call for an ambulance
 Lie casualty down
 Raise head and shoulders slightly
 Tilt casualty's head towards weaker side
to allow fluid to drain out
 Wipe face with damp cloth if they dribble

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 S-A-M-P-L-E
History in Emergency
 S – Signs & Symptoms

 A – Allergies (Food, Medicines)

 M – Medications

 P – Past / Pertinent Medical History

 L – Last Oral Intake

 E – Events leading to present condition

 S-T-A-B-L-E
(In Emergency Room)
 S – Sugar (Hypo/hyperglycemia)

 T – Temperature

 A – Airway

 B – Blood Gases

 L – Lab Works

 E – Empathy 29
Thank You