MODULE III
HISTORY TAKING AND
PHYSICAL EXAMINATION
Module Objectives
Describe the challenges of interviewing a
patient with a suspected STI and the need
to offer confidentiality and privacy
Explain the importance of demonstrating
respect for each patient
List a range of verbal and non-verbal
communication skills to gather information
effectively and ensure patient compliance
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Module Objectives…..
Identify the areas of information to cover
during the interview to make an accurate
syndromic diagnosis
Recall the steps to conduct an efficient
clinical examination
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Brain storming session
How might you feel if you went to health
facility with STI symptoms?
How might you have felt if you were
younger or older?
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INTRODUCTION TO HISTORY
TAKING AND PHYSICAL
EXAMINATION
The three aims of history taking &
P/E are to:
1. Make an accurate and efficient syndromic
STI diagnosis.
2. Establish the patient’s risk of transmitting
or contracting STI.
3. Find out about partners who may have
been infected.
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Things to consider during
history taking and
examination
The patient’s basic needs
The patient may be concerned or embarrassed,
so it is important that the service provider and
the environment set him or her at ease
The environment
Confidentiality and privacy are crucial:
somewhere to talk where others cannot see or
hear – and a particular need for patient
confidentiality
The service provider
Patients need to feel that the service provider
understands and respects them and wants to
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COMMUNICATION SKILLS
NECESSARY FOR ESTABLISHING
RAPPORT
Establishing a good rapport with
the patient
When the service provider makes
interviews, he/she should:
Smile and use a welcoming tone of
voice
Introduce himself/herself
Use the patient’s name
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Establishing a good rapport with
the patient cont…
Offer the patient a seat
Begin the history-taking only when
there is privacy
Make eye contact if culturally
appropriate
Be respectful and understanding –
especially when the patient
stammers and hesitates.
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Non verbal Communication
Skills
Maintain appropriate eye contact
Listen carefully to what the patient says
Reflect the patient’s behavior
Stay as close to the patient as is culturally
acceptable
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General Verbal Skills
Always phrase your questions politely and
respectfully, however busy or rushed you
may be
Make your questions specific, so that the
patient knows exactly how to answer
Ask one question at a time: double
questions confuse
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General Verbal Skills…
Keep your questions free of moral
judgments
Avoid ‘leading’ questions that ask the
patient to agree with you: let people answer
in their own words
Ask the patient’s permission before asking
about his/her STI or sexual behaviour
Use words that the patient understands
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Specific Verbal Skills
Facilitation
Using words, sounds or gestures to
encourage patients to keep on talking
Direction
Useful when a patient is confused and
does not know where to begin, or when
they are talking quickly and mixing up
issues of concern.
It helps people to sort out ideas and give
information in a sequence
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Specific Verbal Skills…
Summarizing and checking
Enable service provider to check that
he/she has understood the patient
correctly. The patient is also able to correct
any misunderstanding.
Use this skill when the patient has
mentioned a number of things that you
want to confirm
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Specific Verbal Skills…
Empathy
Important skill when dealing with the
patient’s feelings
Reassurance
To show that you accept the patient’s
feelings and that the problem need not
last forever
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Specific Verbal Skills…
Expressing partnership
Confirms a commitment to help the
patient
This commitment could be with the
service provider personally, or on behalf
of the health centre team
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HISTORY TAKING
Components of STI syndromic
Hx Taking
The patient's general details.
The patient's present illness.
Medical history.
Sexual history.
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Guide for History-Taking
1. General details
Age
Marital status
Locality or address
Employment
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Guide for History-Taking…
2. Present illness
Presenting complaints and duration
Men:
– If a urethral discharge – pain while passing
urine? Frequency?
– If scrotal swelling – Onset? Presence of pain?
History of trauma and concomitant urethral
discharge?
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Guide for History-Taking…
Women:
– If a vaginal discharge – amonut, color, odor,
associated pruritis, pain while passing urine?
Frequency? Risk assessment positive?*
– Lower abdominal pain – vaginal bleeding or
discharge? The onset, type of pain, radiation,
severity, presence of vaginal discharge, last
menstrual period, and systemic symptoms like
fever, nausea and vomiting
– Painful or difficult pregnancy or childbirth?
– Painful or difficult or irregular menstruation?
– Missed or overdue period?
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Guide for History-Taking…
Men and women:
If a genital ulcer – is it painful? Recurrent?
Appearance? Spontaneous onset? Other
symptoms, such as itching or discomfort?
If an inguinal swelling - is it painful? Associated
with genital ulcer? Swellings elsewhere in the
body?
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Guide for History-Taking…
3. Medical history
Any past STI – type? Dates? Any treatment and
response?
Other illness – type? Dates? Any treatment and
response? Results of tests?
Medications being taken currently
Drug allergies.
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Guide for History-Taking…
4. Sexual history
Currently sexually active?
New partner in the last three months?
Risk assessment
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PHYSICAL EXAMINATION
Examining Male patients for STI
syndromes
Examination of a male patient can easily be
done in a standing position, but the lying
position can as well be used
The patient should be asked to expose the
area from the chest to knees for physical
examination
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Examining male patients for STI
syndromes….
Palpate the inguinal region in order to detect
the presence or absence of enlarged lymph
nodes & buboes
Palpate the scrotum, feeling for individual
parts of the anatomy:
– testes
– spermatic cord
– epididymis
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Examining male patients for STI
syndromes….
Examine the penis, noting any rashes or
sores. Then retract the foreskin if present,
and look at the:
– glans penis
– urethral meatus
If you cannot see an obvious urethral
discharge, milk the urethra or ask the patient
to milk the urethra gently in order to express
any discharge
Record your findings
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Examining Female patients for STI
syndromes
Ask for patients to lie down comfortably on a
couch for genital examination.
Ask patients to expose the area from the
chest to knees for examination
The patient should be covered with a sheet to
maintain dignity and respect
Palpate the abdomen for pelvic masses and
tenderness, taking great care not to hurt the
patient
Palpate the inguinal region in order to detect the
presence or absence of enlarged lymph nodes &
buboes
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Examining female patients for STI
syndromes….
Ask the patient to bend her knees and separate her
legs, then examine the vulva, anus and perineum
The physical examination may include, where
possible, an internal pelvic examination involving
Bimanual examination to check for active PID;
shape, size and position of uterus for uterine
masses, for example, pregnancy
Speculum examination to check for the
nature of the vaginal discharge, purulent
cervicitis and/or erosions
Record your findings
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For both Male and Female
General examination:
An inspection of the skin should be carried
out to look for any rash, sores and
Then lymph node palpation should be
carried out to determine the presence of
enlarged lymph nodes in the anterior and
posterior cervical region, submental,
suboccipital, axillary and epitrochlear areas.
Examination of the oral cavity: The oral
cavity should be carefully visualized with a
torch for ulcers, candidiasis, leukoplakia,
gingivitis
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Time for Role play 3.2
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Lots of Thanks!
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