2023 2 13 MBBS Introduction and History Taking

Introduction & History taking
Dr. Cuilian Dai MD. FACC, Professor
Xiamen Cardiovascular Hospital, Xiamen University
1
PART I: Introduction
1. What is the patient's purpose ?

-chief complain
-history of patient's present
-physical examination and lab test
2. What 's the diagnosis
3. How to treatment
4. Medical record
2
Course Description
The course includes 6 parts which covering physical examination, instruments

examination and laboratory test.
1. symptomatology
2. Inquiry
3. physical examinations
4. medical record writing
5. the diagnosis of diseases
6. Blood test and electrocardiogram diagnosis and ultrasound diagnosis
3
Objectives
1. Master the mechanisms or pathogenesis of common symptoms

2. Master the techniques of taking the patient`s history
3. Master the common methods of physical examination
4. Master the mechanisms of typical signs and their clinical values
5. Master the principle of how to make a medical record
6. Master the patterns of normal ECG
4
Objectives
1. Be familiar with the features of abnormal ECG in common cardiac disease

2. Be familiar with the laboratory examinations and their clinical values
3. Cultivate the ability to analyze and synthesize clinical data, writing complete
medical record
4. Understand the mechanism of the ECG and ultrasound diagnosis
5
Approach to the patient
Being a “good” doctor
Confidentiality and consent
Personal responsibilities
Dress and demeanor
Communication skills
Expectations and respect
Hand washing and cleanliness
6
Being a good doctor
• Are knowledgeable
• Respect people, healthy or ill, regardless of who they are
• Support patients and their loved ones when and where needed
• Always ask courteous questions , let people talk and listen to
them carefully
• Promote health as well as treat disease
• Give unbiased advice, let people participate actively in all
decisions related to their health and healthcare, assess each
situation carefully and help whatever the situation
7
Being a good doctor
• Use evidence as a tool, not as a determinant of practice

• Humbly accept death as an important part of life; and help people make the best
possible arrangement when death is close
• Work cooperatively with other members of the healthcare team
• Are proactive advocates for patients, mentors for other health professionals and ready
to learn from others, regardless of their age, role or status
8
Being a good doctor
• Doctors also need a balanced life and to care for them are happy and healthy,
caring and competent, and who care for people throughout their life.
• When you are dealing with patients, always consider your:
• A: attitude- how would I feel in the patients
• B: behavior- always treat patients with kindness and respect
• C: compassion- recognize the human story that accompanies each illness
• D: dialogue- listen to and acknowledge the patient
9
• As a student and a doctor you will be given private and intimate information about
patients and their families.
• There are exceptions to the general rules governing patient confidentiality, where
failure to disclose information would;
• Put the patients or someone else at risk of death or serious harm
• Might assist in the prevention, detection or prosecution of a serious crime
Contact the senior doctor in charge of the patient`s care immediately

and inform him or her of the situation
10
• Take all reasonable steps to ensure that consultation and examination of a patient is
private
• Never discuss patients where you can be overheard or leave patient`s records, either
on paper or on screen
• Always obtain consent or other valid authority before undertaking any examination or
investigation, providing treatment or involving patients in teaching or research
• Clearly record your finding in the patient`s case notes immediately after the
consultation.
11
Personal Responsibilities
• Always look after yourself and maintain your own health
• Your professional position is a privileged one
• Do not express your personal beliefs
12
Dress And Demeanour
• Smart, sensitive and modest dress is appropriate
• Have short or three-quarter-length sleeves or roll long sleeves up, away from your wrists,
before examining patients of carrying out procedures
• Introduce yourself fully and clearly to your patients or relative
13
Communication with patients and their relative
• A consultation is a meeting of two experts: you as the clinician and the patient as
an expert on his own body and mind
Communication with your work team
• Try to act as a positive role model and motivate and inspire your colleagues.
• Always respect the skills and contributions of your colleagues and communicate
effectively with them particularly when handing over care.
14
Many patients have high expectations for their diseases
• Medicine often involves seeing and

treating patients with common
conditions and chronic diseases
where we may only be able to
provide palliation or simply bear
witness to patients’ suffering
American doctor Trudeau's epitaph
15
• Hand washing is the single most

effective way to prevent the
spread of infection.
• It is your responsibility to prevent

the spread of infection and
routinely wash your hands after
every clinical examination.
16
SUMMARY ABOUT
Approach to the patient
Being a “good” doctor
Personal responsibilities
Dress and demeanor
17
PART 2: History taking
• All patients seek explanation and meaning for their symptoms.
18
Patient
satisfaction
• The first and major part of any

consultation is talking with your patient
• Good communication supports the To Doctor

building of trust between you and your Health
improve satisfaction
patient and helps you provide clear and
simple information
Use time
more
effectively
19
Communication means much more than

‘taking a history’
Poor communication leads to

misunderstanding
20
Beginning
• develop your own consulting

style; sharing Active
listening
• consultation frameworks are BASICS
useful places to start
Context Systematic
enquiry
Information
gathering
21
BEGINNING
1. Setting up
① Preparation: read your patient’s records and any transfer or admission letters before
you see your patient.
Where will you see your patient?: choose a quiet, private space
How will you sit?
22
BEGINNING
1. Setting up
① Preparation: read your patient’s records and any transfer or admission letters before you
see your patient.
② Starting your consultation
• Introduce yourself, and anyone else who is with you.

• Use your patient’s and your own names to confirm identity.
• It may be appropriate to shake hands.
• If you are a student, inform the patient that you are in training; patients are
usually eager to help.
• Write down facts that are easily forgotten, e.g. blood pressure readings or
family tree, but writing notes should not interfere with the consultation.
23
• Good morning, Mrs Jones. I have got the right person, haven’t I?
• I’m Mr White. I’m a fourth-year medical student. I’ve been asked to come and talk
with you and examine you.
• It might take me 20–30 minutes, if that’s all right.
• I see that you can’t really get out of bed so we’ll need to talk here.
• I’ll pull the screens round. I’m sorry it’s not very private. If I ask you a question that you
don’t want to answer in case other people overhear, then just say so.
• I’ll need to make a few notes so I don’t forget anything important.
• Now, if I’m writing things down, it doesn’t mean I’m not listening. I still will be.
• Are you happy with all that?
24
BEGINNING
1. Setting up
① Preparation: read your patient’s records and any transfer or admission letters before you
see your patient.
② Starting your consultation
Active listening
Hearing your patient’s story about his illness experience
Active listening means encouraging the patient to talk
Clarify anything you do not understand
Ask an Open question to encourage the patient to talk or a Closed question to

invite the “yes”or “no”answers
25
Can we start with you telling me what has happened to bring you into hospital? (Opening)
Well, I’ve been getting this funny feeling in my chest over the last few months. It’s been getting worse and
worse but it was really awful this morning. I got really breathless and felt someone was crushing me.
Can you tell me a bit more about the crushing feeling? (Open questioning)
Well, it was here, across my chest. It was sort of tight.
And did it go anywhere else? (Clarifying)

Well, maybe up here in my neck.
So, you had a tight pain in your chest this morning that went on along time and you felt it in your
neck? (Summarising)
You’ve had the pain for the last few months. Can you tell me more? (Relecting and open
questioning)
Well, it was the same but not that bad, though it’s been getting worse recently.
26
OK. Can you remember when it first started? (Clarifying)

Oh, 3 or 4 months ago.
Does anything make it worse? (Open questioning) So, for a few months you’ve had a
tightness in your chest, which gets worse
Well, if I go up steps or up hills that can bring it on.
going up hills and upstairs and which
What do you do? goes away if you use your spray.
Stop and sometimes take my puffer. Sometimes you feel the pain in your neck.
But today it came on and lasted longer
Your what? (Clarifying)
but felt the same. Have I got that right?
This spray the doctor gave me to put in my mouth. (Summarising)
Can you show me it, please?
OK. No, it was much worse this morning.
And what does it do? (Clarifying)
Well, it takes the pain away, but I get an awful headache with it.
27
find out about your patient’s ICE:
• I: Ideas on what is happening to him

• C: Concerns in terms of the impact on him
• E: Expectations of the illness and of you, the doctor.
28
Empathy
What is empathy and how do you express it?
Empathy is not sympathy, the expression of sorrow; it is much more. It is helping your patients
feel that you understand what they are going through. Try to see the problem from their point
of view and relate that to them.
Think how you would feel and imagine yourself in this situation. Express empathy through
questions which show you can relate to your patient’s experience.
29
Understanding your patient’s context
your patients’ personal constraints and supports, including

• where they live,
• Who they live with
• where they work
• who they work with,
• what they actually do
• their cultural and religious beliefs
• their relationships and past experience.
they are important in any long- term doctor–patient relationship.
30
Understanding your patient’s context
✓ Tactful enquiring about your patient’s relationships and the home environment.
✓ Patients’ beliefs influence healthcare.
✓ consultation also gives you an opportunity to bring up issues around preventive
activities
• smoking cessation
• dealing with obesity
• drug or alcohol dependency
• illnesses that run in the family
31
Sharing information and agreeing goals
Clarify and summarise what you say

Use words that the patient will understand and tailor the explanation to your patient.
Explain what you have found and what you think this means.
Give important information first and check what has been understood.
Use simple language and ensure your patient understands the treatment options and
likely prognosis.
32
Engaging your patient
Make sure patients are involved in any decisions
Be sensitive to your patients’ body language
Whenever possible help decision making by giving written information to take

home or by suggesting other sources of information
Check they have understood you and discuss any investigations or

treatment you think might be needed, including risks or side-effects
33
Engaging your patient
About the specific check and treatment, you will be able to negotiate a mutually
agreed plan
Try to agree realistic goals
Arrange for follow-up if necessary or give the patient some idea about when to
return
34
2. Difficult situations
Your patient has communication difficulties
• Use an interpreter, but remember to address the patient, not the interpreter.
• Write things down for your patient if he can read.
• Employ lip reading or sign language.
• Involve someone who is used to communicating with your patient.
35
Your patient has cognitive difficulties
• Be alert for early signs of dementia

• You may have to rely on help from relatives or carers.
• If you do suspect this, use a memory or mental status test
36
Sensitive situations
• ask personal or sensitive questions and examine intimate parts.

• a patient who may have a sexually transmitted disease.
• Indicate that you are going to ask questions in this area, and make sure the
conversation is entirely private.
37
Sensitive situations
• Ask permission sensitively if you need to examine intimate areas.

• First warn your patient
• seek permission to carry out an examination, explaining what you need to do.
• Always offer a chaperone, even if you are of the same gender as the patient.
• Record the chaperone’s name and position. If patients decline the offer,
respect their wishes and record this in the notes.
38
Your patient is emotional
• Ill people feel vulnerable and may become angry or distressed.

• Talkative patients or those who want to deal with a lot of things at once
• Set professional boundaries if your patient becomes overly familiar
39
• Use appropriate eye contact

• Use appropriate hand gestures
• Respect personal space
Trans-cultural
awareness • Consider physical contact between sexes, e.g. shaking hands
• Be sensitive to cultures and beliefs surrounding illness
• Ask yourself what should happen as death approaches?
• Ask yourself what should happen after death?
40
Confidentiality is your first priority

You may need to obtain information about your patient from someone
else: usually a relative and sometimes a friend or carer
Third-party
information
Ask your patient’s permission and have the patient present to
maintain confidentiality
If the patient cannot communicate, you will have to rely on family and
carers to understand what has happened to the patient.
41
Third parties may approach you without your patient’s knowledge. Find
out who they are, what their relationship to the patient is, and whether
Third-party your patient knows the third party is talking to you.

information
to confirm the truth if third parties tell you about sensitive matters of your
patient
42
• Breaking bad news is one of the most difficult communication tasks you will
face
Breaking • Follow the principles of good communication.
bad news
• Speak to your patient in a quiet private environment
• Ask patients who else they would like to be present
• to find out how much they know and how much they want to know
• Plan in advance what you need to share
• do not get lost in a lot of detail.
• Respond to their feelings
43
GATHERING INFORMATION
1. The history of the presenting symptoms
① Diagnosis :
Experienced clinicians make a diagnosis by recognising patterns of symptoms
With experience you will refine your questions according to the presenting
complaint
you should then have a list of possible diagnoses (a differential diagnosis),

before you examine the patient
44
① Diagnosis :
For example
A 65-year-old, M, smoker
His age and smoking status Coronary artery disease
A cough for 2 months Long cancer or chronic obstructive

pulmonary disease(COPD)
Coronary artery disease,
Chest pain
aortic dissection
Infection Pulmonary enbolism
Lung cancer
Haemoptysis Tuberculosis, left heart failure 45
① Diagnosis :
46
① Diagnosis :
What is your main problem? (Open question)
Can you please tell me more about the cough?(Open question)
Can you tell me about the pains? (Open question)
Does anything else bring on the pains? (Open and prompting question)
What colour is the phlegm? (Closed question, focusing on the symptom offered)
47
② What sort of pathology does the patient have? :
• Think about which pathological process may account for the symptoms
48
② What about physical signs?
• Some diseases have no physical signs

• Other conditions almost always produce physical signs
• have a clear differential diagnosis before examining the patient
• Always reconsider your diagnosis
49

Pain
50
The effects of chronic pain: questions you might ask
1. The history of the presenting
symptoms
Associated symptoms
Effects on lifestyle
Note that pain affects several

areas of a patient `s life but that
These are interlinked
51
Attitudes to illness
52
GATHERING INFORMATION A summary of useful starting questions for eachsystem

53
2. Past medical history
Past medical history may be relevant to the presenting symptoms
These questions will elicit the key information in most patients:

• What illnesses have you seen a doctor about in the past?
• Have you been in hospital before or attended a clinic?
• Have you had any operations?
• Do you take any medicines regularly?
54
3. Drug history
Begin by checking any written sources of information
Example of a drug history
55
3. Drug history
concordance
and adherence
• Half of all patients do not

take prescribed medicines as
directed.
• Concordance implies that

the patient and doctor have
negotiated and reached an 56
agreement on management Year since diagnosis
•
• adherence with therapy is
likely (though not
guaranteed) to improve.
Lancet 2011; 378: 1231–43

3. Drug history
• Ask patients to describe :
✓ how and when they take their medication.
Concordance and adherence
✓ Give them permission to admit that they do not
take all their medicines by saying, for example,
• Ask if your patient has ever had an allergic reaction to a
‘That must
medication be difficult to remember.’
or vaccine.
Drug allergies/reaction
• Note other allergies, such as foodstuffs or pollen.
• Record true allergies prominently in the patient’s case

records, drug chart and computer records
• If patients have had a severe or life-threatening allergic

reaction, advise them to wear an alert necklace or
bracelet.
GATHERING INFORMATION Ask all patients who may be using drugs about non-prescribed drugs
3. Drug history
Non-prescribed drug use

4. Family history
• Start with open questions, such as
✓ ‘Are there any illnesses that run in your family?’
• Follow up the presenting symptoms with a question like
✓ ‘Have any of your family had heart trouble?’
✓ Ion channel disease
Genetic heart diseases ✓ Cardiomyopathy

✓ Hypertension
✓ Familial hypercholesterolemia
Ask about the health of other household members, since this may suggest
environmental risks to the patient.
5. Social history and lifestyle
• To assess the social circumstances of your patient.

• M ay be relevant to the causes of their illness and may also influence the
management and outcome.
Smoking • tobacco use increases the risk of obstructive lung disease, cardiac and vascular
disease, peptic ulceration, et al
✓ Ask if your patient has ever smoked; if so, enquire
✓ what age they started at
✓ whether they still smoke now.
✓ the average number of cigarettes per day over the
years
✓ what form of tobacco
Smoking • Causes extensive pathology

• Always ask patients if they drink
Alcohol alcohol
• If they do drink, ask them to describe
• how much and what type (beer,
wine, spirits) they drink in an
average week.
• The UK Department of Health now

defines hazardous drinking as
anything exceeding 14 units per
week for both men and women.
1 unit (10 mL of ethanol)

Smoking
Alcohol
• Work profoundly influences health
Occupational history • Ask all patients about their occupation
and home environment • Clarify what the person does at work
any chemical or dust exposure
Smoking
Alcohol
Unusual or tropical infections
Occupational history Air travel-middle-ear problems or deep vein thrombosis.
and home environment The incubation period may indicate the likelihood of many
illnesses but some diseases, such as vivax malaria and human
Travel history immunodeficiency virus, may present a year or more after
travel.
List the locations visited and dates.

Smoking
Alcohol
Occupational history
and home environment
Travel history
Take a full sexual history only if the context or pattern of
Sexual history symptoms suggests this is relevant
Signal your intentions: ‘As part of your medical history, I

need to ask you some questions about your
relationships. Is this all right?’
• Systematic enquiry uncovers symptoms that may have been forgotten
GATHERING INFORMATION • Start with ‘Is there anything else you would like to tell me about?’
6. Systematic enquiry • Asking about all of these is inappropriate and takes too long, so
judgement and context are used to select areas to explore in detail
6. Systematic enquiry
7. Closing the interview
① Using simple language, briefly explain your interpretation of the

patient’s history and outline the likely possibilities.
② Make sure patients are involved in any decisions by suggesting possible
actions and encouraging them to contribute their thoughts
③ you should be able to negotiate an agreed plan for further investigation
and follow-up
④ Tell them that you will communicate this plan to other professionals
involved in their care
SUMMATY OF History taking
Beginning
• develop your own consulting

style; sharing Active
listening
• consultation frameworks are BASICS
useful places to start
Context Systematic
enquiry
Information
gathering
68
69
70

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Introduction & History taking

Dr. Cuilian Dai MD. FACC, Professor

Xiamen Cardiovascular Hospital, Xiamen University

1. What is the patient's purpose ?

The course includes 6 parts which covering physical examination, instruments

1. Master the mechanisms or pathogenesis of common symptoms

1. Be familiar with the features of abnormal ECG in common cardiac disease

Being a “good” doctor

Confidentiality and consent

Dress and demeanor

Expectations and respect

Hand washing and cleanliness

• Use evidence as a tool, not as a determinant of practice

• When you are dealing with patients, always consider your:

• A: attitude- how would I feel in the patients

• B: behavior- always treat patients with kindness and respect

• C: compassion- recognize the human story that accompanies each illness

• D: dialogue- listen to and acknowledge the patient

Contact the senior doctor in charge of the patient`s care immediately

• Always look after yourself and maintain your own health

• Your professional position is a privileged one

• Do not express your personal beliefs

• Smart, sensitive and modest dress is appropriate

• Introduce yourself fully and clearly to your patients or relative

Communication with your work team

• Medicine often involves seeing and

American doctor Trudeau's epitaph

• Hand washing is the single most

• It is your responsibility to prevent

Being a “good” doctor

Confidentiality and consent

Dress and demeanor

Expectations and respect

Hand washing and cleanliness

• All patients seek explanation and meaning for their symptoms.

• The first and major part of any

• Good communication supports the To Doctor

Communication means much more than

Poor communication leads to

• develop your own consulting

How will you sit?

• Introduce yourself, and anyone else who is with you.

Ask an Open question to encourage the patient to talk or a Closed question to

Well, it was here, across my chest. It was sort of tight.

And did it go anywhere else? (Clarifying)

OK. Can you remember when it first started? (Clarifying)

find out about your patient’s ICE:

• I: Ideas on what is happening to him

What is empathy and how do you express it?

Understanding your patient’s context

your patients’ personal constraints and supports, including

they are important in any long- term doctor–patient relationship.

Understanding your patient’s context

Sharing information and agreeing goals

Clarify and summarise what you say

Sharing information and agreeing goals

Engaging your patient

Make sure patients are involved in any decisions

Be sensitive to your patients’ body language

Whenever possible help decision making by giving written information to take

Check they have understood you and discuss any investigations or

Sharing information and agreeing goals

Engaging your patient

Try to agree realistic goals