MODULE III
HISTORY TAKING AND PHYSICAL
EXAMINATION
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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
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
INTRODUCTION TO HISTORY
TAKING AND PHYSICAL
EXAMINATION
The three aims of history taking and examination 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.
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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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
listen
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
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.
Non verbal communication skills
Maintain appropriate eye contact
Listen carefully to what the patient says
Reflect the patient’s behaviour
Stay as close to the patient as is culturally
acceptable
General Verbal Skills
Avoid frequent inturaption
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
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
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
Specific Verbal Skills
Summarizing and checking
Enable service provider to check that he/she
have understood the patient correctly and
patient will have opportunity to correct any
misunderstanding.
Use this skill when the patient has mentioned
a number of things that you want to confirm
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
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
HISTORY TAKING
Components of STI
syndromic Hx
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
Guide for History-Taking continued
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?
Guide for History-Taking continued
Women:
– If a vaginal discharge – amount, 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
– Missed or overdue period?
– Recent delivery or miscarriage
Guide for History-Taking continued
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?
Guide for History-Taking continued
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.
Guide for History-Taking continued
4. Sexual history
Currently sexually active?
New partner or multiple partners in the last
three months?
Risk assessment
PHYSICAL EXAMINATION
General measures:
Make patient at ease
Take informed oral consent
Maintain privacy
Allow attendance by chaperon( 3rd person)
while maintaining privacy
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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
Examining male patients for STI
syndromes
Palpate the inguinal region in order to
detect the presence or absence of enlarged
lymph nodes and buboes
Palpate the scrotum, feeling for individual
parts of the anatomy:
– Testes
– Spermatic cord
– Epididymis
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
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 and buboes
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
For both male and female
General examination:
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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