 Ibn Abbas reported: The Messenger of

Allah said, “There are two blessings in

which many people incur loss. (These
are) health and free time (for doing
good).” [Al-Bukhari]
 Welcome the patient - ensure comfort
and privacy
 Know and use the patient's name -
introduce and identify yourself
 Set the Agenda for the questioning
 Use open-ended questions initially
 Negotiate a list of all issues - avoid
excessive detail initially
› Chief complaint(s) and other concerns
› Specific requests (i.e. medication refills)
 Clarify the patient's expectations for this
visit - ask the patient "Why now?"
 Elicit the Patient's Story
 Return to open-ended questions
directed at the major problem(s)
 Encourage with silence, nonverbal cues,
and verbal cues
 Focus by paraphrasing and summarizing
 Chief complaint
 History of Present Illness
 Past Medical History
 Past Surgical History
 Allergies
 Medications
 Social History
 Family History
 Review of Systems
 Abdullah bin Amr Bin Al-As reported: A
man asked the Messenger of Allah:
“Which act in Islam is the best?” He
replied, “To give food, and to greet
those who you know and those you do
not know.” [Al-Bukhari and
Muslim]
 This is why the patient is here in the
emergency room or the office

 Examples:
› Shortness of breath
› Chest pain
› Nausea or vomiting
 This is the detailed reason why the
patient is here
 It is the why, when and where, etc…
 Use the OPQRSTA approach to cover all
aspects of information
 OPQRSTA
› Onset
 When did the chief complaint occur
› Prior occurrences of this problem
› Progression
 Is this problem getting worse or better
 Is there anything that the patient does that makes it
better or worse
› Quality
 Is there pain, and if so what type—how would the
patient describe it is words
 OPQRSTA (continued)
› Radiation
 Do the symptoms radiate to anywhere in the
body, and if so, where?
› Scale
 On a scale of 1 to 10, how bad are the
symptoms
› Timing
 When do the symptoms occur?
 At night, all the time, in the mornings, etc…
 OPQRSTA (cont)
› Associated symptoms
 Any other info about the chief complaint that
has not already been covered
 Ask if there is anything else that the patient has
to tell about the chief complaint
 These are the medical conditions that
the patient has chronically and that they
see a doctor for.
 Examples:
› Hypertension, GERD, Depression, Congestive
heart failure, hyperlipidemia, Diabetes,
Asthma, Allergies, Thyroid problems, etc…
 These are any previous operations that
the patient may have had
 Make sure to put how old the patient
was when they occurred
 Include even those that occurred in
childhood
 Examples:
› Tonsillectomy, Hysterectomy,
Appendectomy, Hernias, Cholecystectomy
 Include all meds the patient is on—even
over the counter meds and herbals
 Try to include the dosages if the patient
knows them
 Include how often the patient takes
them
 Make sure to ask about medication
allergies and the reaction that the
patient has to them
 Ask about latex, food and seasonal
allergies
 Things to include:
› Occupation
› Marriage status
› Tobacco use—how much and for how long
› Alcohol use
› Illicit drug use
› Immunization status
› If pertinent, sexually transmitted disease
history
 Here in Family Medicine, we also include:
› Code status
 Does the patient wish to have resuscitative
measures taken in the event of their heart
stopping, including chest compressions and/or
a tube down their throat
 DNR—do not resuscitate
 DNI—do not intubate
 Ask if the patient’s parents,
grandparents, siblings or other family
members had any major medical
conditions
› Examples:
 Heart disease, heart attacks, hypertension,
hyperlipidemia, diabetes, sickle cell disease
 The review of systems is just that, a series of
questions grouped by organ system including:
 General/Constitutional
 Skin/Breast
 Eyes/Ears/Nose/Mouth/Throat
 Cardiovascular
 Respiratory
 Gastrointestinal
 Genitourinary
 Musculoskeletal
 Neurologic/Psychiatric
 Allergic/Immunologic/Lymphatic/Endocrine
 General
 Heart
 Lungs
 Abdomen
 Extremities
 HEENT
 Neck
 GU if pertinent to the chief complaint
 Make sure to include vital signs as part of
this

 Develop a systematic approach for

doing the physical exam
 This is what you think is wrong with the
patient, and what you plan to do initially
during admission
 Example:
› A/P: 1. Chest pain. We will admit the
patient to the chest pain protocol. We will
get EKG every 8 hours times three, and
cardiac enzymes every eight hours times
three, get a CBC, CMP, etc….
 This will all be dictated as part of the
official medical record
 Beginning parts:
› State your name
› Admission date
› Attending physician
› Resident physician (that’s YOU)
 After stating the beginning info:
 State the chief complaint and the
remainder of the history
 Make sure you title each component
 Make sure you include the vital signs and
all physical exam findings
 This will all become like second nature
after you have done a few.
 Just stick to the same way you do the H
and P each time, and you will do all
right.
 A those who practice medicine
without knowledge and expertise of
medicine will themselves be
responsible for their act
(Trimzi; Ibne majah)
 When the drugs are prescribed
according to the diagnosis of the
disease, Allah bestows cure. (Nisai,
Ibne majah)
 Out-pt or emergency room history
?specific complaint is pinpointed ? diagnosis

 Clerking of pt admitted for elective surgery

object
? to assess that the treatment planned correctly
indicated and pt is suitable for that operation.
 Personal information : Age, sex, marital status,
occupation, etc……
 the present complaint (c/o).
 History of present complaint.
 Elaboration on the system involved.
 Systemic enquiry.
e. Past history ? surgical, medical
f. Drug history
g. Family history
h. Social history
1. GIT: Appetite, Vomiting, Regurgitation, etc.
 Respiratory System ? cough, haemoptysis, Dyspnea….
 C.V.S: * Breathlessness, palpations, chest pain…
* Peripheral vessels: Intermittent, claudication, rest pain.
 Urogenital system: micturition, loin pain supropubic pain.
 Nervous system: Tremor, fainting attacks, fits, weakness…
 Musculor skeletal ? muscle pains, joint swelling
 Pain
 Lump
- Site.
- Onset.
- Severity ? wake him up, need analgesics
Rather than: mild, severe.
- Nature: Buring, stabing, coliky.
- Progression ? - begin ç maximum, then remains steady.
- steadily increase till maximum then gradual
decline.
- Duration.
- Aggravating and releaving factors
- Radiation.
 Duration
 How discovered
 Symptoms ? pain
 Changes ? ?in size
 Other lumps
 Any cause ? Trauma
 General Examination:
- First part ? during taking history ? posture,
speech,etc…
- vital signs ? pulse, BP, temp
Eyes
 Pupil reaction to light
 Sclera  jaundice
 Conjuction  paller
 Movement 
 Exophthalmos
 Fundoscopy
Ears and Nose
 Usually forgotten on ex:
 External auditory canal
 Eardrum
 Nostrils
Neck
 Jugular veins
 Trachea
 Lymph nodes
 Thyroid
 Position
 Colour and texture of skin
 Temperature
 Tenderness
 Shape
 Size
 Surface
 Edge
 Consistency
 Pulsatile, compressibility (venous malformations)
 Reducibility
PREPARATION:
Warm and private room
Good light
Comfortable cough or bed
Exposure: nipple to knee
Get the patient to relax
The position of the examiner
Inspection
Palpation
Percussion
Auscultation
INSPECTION:
Shape of abdomen
Scars, sinuses & fistulae
Distended veins
Lumps
Pigmentation
Movement
PALPATION:
Superficial :
 Tenderness
 Rebound
 Ganding
Deep palpation:
 Masses
 Organs
PERCUSSION:
All abdomen  spec. over masses
Fluid thrill
Shifting dullness
AUSCULTATION:
Bowl sounds
Aorta and iliac anteries - Bruit
Succusion splash
THANK
YOU !!!!!