History Taking and Physical Examination- An Overview

1. History Taking and Physical Examination:
An Overview
Prepared and presented by
Marc Imhotep Cray, M.D.
Companion eNotes:
The Comprehensive History and Physical Examination

2. Marc Imhotep Cray, M.D.
The Comprehensive H&P
2
 Comprehensive H&P is typically obtained when a physician sees a
patient for first time in a general medical setting, or when a patient is
admitted to hospital
 One exception is when pt. presents wan emergent complaint and
initiating treatment is a higher priority than obtaining a detailed
history or performing a thorough physical examination
 Almost all other types of documentation, including SOAP (subjective,
objective, assessment, and plan) notes and admission H&Ps, are
variations of comprehensive H&P

3. Marc Imhotep Cray, M.D.
Learning Objectives:
By the end of this presentation the learner should be able:
 To understand the general principles of the approaches to the patient
 To describe the seven components of the comprehensive adult medical
history
 To explain the essential components of preparing for the physical
examination
 To describe the equipment required for the physical examination
 To list the general sequence of the physical examination
 To describe the four cardinal techniques used in preforming the physical
examination
3

4. Marc Imhotep Cray, M.D.
Approaches to Patient: General principles
4
General Objectives
When physician (or student) approaches a patient (pt.) there are four initial
objectives:
1. Obtain a professional rapport with pt. and gain his confidence
2. Obtain all relevant information which allows assessment of illness, and
provisional diagnoses
3. Obtain general information regarding pt., his background, social situation
and problems
 In particular it’s necessary to find out how the illness has affected him, his family,
friends, colleagues and his life
4. Understand pt.’s own ideas about his problems, his major concerns & what
he expects from hospital admission, outpatient or general practice visit

5. Marc Imhotep Cray, M.D.
Approaches to Patient: General principles(2)
5
Specific objectives
In taking a history (Hx) or making an examination (PE)
there are two complementary aims:
1. Obtain all possible information about a pt. and
his illness (a database)
2. Solve problem as to diagnoses

6. Marc Imhotep Cray, M.D.
Approaches to Patient: GPs (3)
6
Analytical approach
 For each symptom (Sx) or sign (Sn) one needs to think of a
differential diagnosis (DDx), and  of other relevant
information (by history, examination or investigation)
which one will need to support or refute these possible
diagnoses
Self-reliance
 The student must take his own history, make his own
examination and write his own clinical records

7. Marc Imhotep Cray, M.D.
Approaches to Patient: GPs (4)
7
What is important when you start?
 At basis of all medicine is clinical competence
 No amount of knowledge will make up for poor technique
 It is essential to learn and practice the basic ABCs of clinical medicine,
introduced in this clinical skills sequence:
 how to relate to patients (communication skills)
 how to take a good history efficiently, knowing which question to
ask next and avoiding leading questions
 how to examine patients in a logical manner, in a set routine which
will mean you will not miss an unexpected sign
 apply yourself
 initially learn by rote which skills are appropriate for each situation

8. Marc Imhotep Cray, M.D.
Differences Between Subjective
& Objective Data
Subjective Data
 What the patient tells you
 The history, from Chief Complaint
through Review of Systems
Example: Ms. G is a 54-year-old
hairdresser who reports pressure
over her left chest "like an elephant
sitting there," which goes into her
left neck and arm.
Objective Data
 What you detect during examination
 All physical examination findings
 Also, laboratory test and other diagnostic/
investigative techniques
Example: Ms. G is an older, over-weight white
female, who is pleasant and cooperative.
Height 5’4 weight 150 lbs., BMI 26, BP 160/ 80,
HR 96 and regular, respiratory rate 24,
temperature 97.5 F
8

9. Marc Imhotep Cray, M.D.
“An History & Physical Exam” Caveat
9
While a good deal of attention may be paid to patient’s
physical examination, over years research has concluded that
most of important information needed to make a diagnosis
about what is wrong with patient comes from patient history
 Thus, asking patient questions and listening carefully to what he
or she says or does not say is often much more helpful than PE or
results of laboratory tests which may just confirm what is learned
during the history

10. Marc Imhotep Cray, M.D.
History Taking
Following we describe the seven components of the
Comprehensive Adult Health History:
1. Identifying Data and Source of the History
2. Chief Complaint(s)
3. Present Illness
4. Past History
5. Family History
6. Personal and Social History
7. Review of Systems
10

11. Marc Imhotep Cray, M.D.
1. Identifying Data
 Identifying data—such as full name, age, gender, occupation,
marital status
 Source of history—usually patient, but can be a family member
or friend, letter of referral or medical records
 If appropriate, establish source of referral, because a written
report may be needed
11

12. Marc Imhotep Cray, M.D.
3. Chief Complaint (CC) /Reliability
Varies according to the patient's memory, trust and mood
The one or more symptoms or concerns causing the patient
to seek care
12

13. Marc Imhotep Cray, M.D.
3. Present Illness (HPI)
 Amplifies Chief Complaint; describes how each symptom
developed
 Includes patient's thoughts and feelings about the illness
 Pulls in relevant portions of the Review of Systems, called
“pertinent positives and negatives”
 May include medications, allergies, habits of smoking and
alcohol, which are frequently pertinent to the present illness
13

14. Marc Imhotep Cray, M.D.
4. Past History (PMH)
 Lists childhood illnesses
 Lists adult illnesses with dates for at least four categories:
 Medical
 Surgical
 Obstetric/gynecologic
 Psychiatric
 Includes health maintenance practices such as immunizations,
screening tests, lifestyle issues, and home safety
14

15. Marc Imhotep Cray, M.D.
Family History (FH)
 Outlines or diagrams age and health, or age and cause of
death, of siblings, parents, and grandparents
 Documents presence or absence of specific illnesses in family,
such as hypertension, diabetes, coronary artery disease , etc.
15

16. Marc Imhotep Cray, M.D.
Personal and Social History (PH & SH)
Describes:
 educational level
 family of origin
 current household
 personal interests and
 lifestyle/habits
 religion/spiritual beliefs
16

17. Marc Imhotep Cray, M.D.
Review of Systems (ROS)
 Documents presence or absence of common symptoms related
to each major body system
17
 Review of systems (or symptoms) is a list of questions, arranged by organ system,
designed to uncover dysfunction and disease can be applied in several ways:
1. As a screening tool asked of every patient that you encounters
2. Asked only of patients who fall into particular risk categories (e.g. reserving questions designed to
uncover occult disease of prostate to men over 50)
3. To better define likely causes of a presenting symptom, as described in HPI section (e.g. patients
w/a chief concern of "chest pain" would be asked detailed cardiac and pulmonary ROS)
 What's the best way to use ROS? Makes sense if following hold true:
o Questions asked reflect an array of common and important clinical conditions
o These disorders would go unrecognized if patient was not specifically prompted
o Identification of these conditions then has a positive impact on morbidity/mortality

18. Marc Imhotep Cray, M.D.
The Comprehensive Adult Physical
Examination
Beginning the Examination: Setting the Stage
 Before you begin the physical examination, take time to prepare for
tasks ahead
 Think through your approach to patient, your professional
demeanor, and how to make patient feel comfortable and relaxed
 Review measures that promote patient’s physical comfort and make
any adjustments needed in lighting and surrounding environment
18
See eNotes: Physical Diagnosis: Approach to the Patient
(66 CORE ESSENTIALS in sequence, as to not have patient reposition unwarranted.)

19. Marc Imhotep Cray, M.D.
 An ophthalmoscope and an otoscope
• If otoscope is to be used to examine children, it should allow for pneumatic otoscopy
 A flashlight or penlight
 Tongue depressors
 A ruler and flexible tape measure, (marked in cm)
 A thermometer
 A watch with a second hand
 A sphygmomanometer
 A stethoscope with following characteristics:
• Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of proper size, align ear pieces with
angle of your ear canals, and adjust spring of connecting metal band to a comfortable tightness
• Thick-walled tubing as short as feasible to maximize the transmission of sound: approximately 30 cm
(12 inches), if possible, and no longer than 38 cm (15 inches)
• A bell and a diaphragm with a good changeover mechanism
Equipment for Physical Examination
19

20. Marc Imhotep Cray, M.D.
Equipment for Physical Examination
cont.
 Gloves and lubricant for oral, vaginal, and rectal examinations
 Vaginal specula and equipment for cytological and bacteriological study
 A reflex hammer
 Tuning forks, ideally one of 128 Hz and one of 512 Hz
 Q-tips, safety pins, for testing two-point discrimination
 Cotton for testing the sense of light touch
 Two test tubes (optional) for testing temperature sensation
 Paper and pen or pencil
20

21. Marc Imhotep Cray, M.D.
PE: Summary of Suggested Sequence
 General survey
 Vital signs
 Skin: upper torso, anterior and posterior
 Head and neck, including thyroid and
lymph nodes
Optional: nervous system (mental status, cranial
nerves, upper extremity motor strength, bulk, tone
and cerebellar function)
 Thorax and lungs
 Breasts
 Musculoskeletal as indicated: upper
extremities
 Cardiovascular, including JVP, carotid
upstrokes and bruits, PMI, etc.
 CV, for S3 and murmur of mitral stenosis
 CV, for murmur of aortic insufficiency
Optional: thorax and lungs-anterior
 Breasts and axillae
 Abdomen
 Peripheral vascular; Optional: skin-lower
torso and extremities
 Nervous system: lower extremity motor
strength, bulk, tone, sensation; reflexes;
Babinski
 Musculoskeletal, as indicated
Optional: skin, anterior and posterior
Optional: nervous system, including gait
Optional: musculoskeletal, comprehensive
 Women: pelvic and rectal examination
 Men: prostate and rectal examination 21

22. Marc Imhotep Cray, M.D.
Cardinal Techniques of
the Physical Examination
 Inspection
 Palpation
 Percussion
 Auscultation
22

23. Marc Imhotep Cray, M.D.
Inspection
Close observation of details of patient's:
 appearance
 behavior, and movement such as facial expression
 mood
 body habitus and conditioning
 skin conditions such as petechiae or ecchymoses
 eye movements
 pharyngeal color
 symmetry of thorax
 height of jugular venous pulsations
 abdominal contour
 lower extremity edema and
 gait 23

24. Marc Imhotep Cray, M.D.
Palpation
Tactile pressure from the palmar fingers or finger pads to assess:
 areas of skin elevation or depression
 warmth, or tenderness
 lymph nodes
 pulses
 contours and sizes of organs and masses and
 crepitus in the joints
24

25. Marc Imhotep Cray, M.D.
Percussion
 Use of striking or plexor finger, usually third digit, to deliver
a rapid tap or blow against distal pleximeter finger, usually
distal third finger of left hand laid against surface of
chest or abdomen, to evoke a sound wave such as
resonance or dullness from underlying tissue or organs
• This sound wave also generates a tactile vibration against
pleximeter finger
25

26. Marc Imhotep Cray, M.D.
Auscultation
Use diaphragm and bell of stethoscope to detect characteristics of:
 heart
 lung and
 bowel sounds
including: location, timing, duration, pitch, and intensity
• For heart this involves sounds from closing of four valves
and flow into the ventricles as well as murmurs
 Auscultation also permits detection of bruits or turbulence over
arterial vessels
26

27. Marc Imhotep Cray, M.D.
Comprehensive Hx and PE Capsule
27
History of Present Illness (HPI)
The Rest of the history:
Past Medical History(PMH)
Past Surgical History (PSH)
Medications (Meds.)
Allergies/Reactions
Social and Personal History:
(Smoking, Alcohol, Drugs of abuse)
Obstetric (where appropriate)
Sexual Activity
Family History (FH)
Work/Hobbies/Other
Military Service
Adult Review of Systems (ROS)
General Appearance
Vital Signs (VS)
Eye Exam
Head and Neck Exam
Lung Exam
Cardiovascular Exam
Exam of the Abdomen
Breast Examination
Male Genital and Rectal Exam
Exam of Upper Extremities
Exam of Lower Extremities
Musculo-Skeletal Examination
Neurological Examination
HEENT

28. Marc Imhotep Cray, M.D.
The “differential of consequence”
(DOC)
28
Develop a focused differential of things that may kill the patient or that
you cannot afford to miss This is called the “differential of
consequence” (DOC)
 For example, if your pt. comes into ED w left-sided chest pain, don’t
waste time and energy on ruling out shingles
o Instead, focus on things like MI, pulmonary embolism (PE),
pneumonia, and pericarditis
 Once you have your DOC think of which tests you can order in ED to
confirm these conditions or rule them out
 Bear in mind, however, that tests ordered in ED must have a quick
(less than 2-hour) turnaround time

29. Marc Imhotep Cray, M.D.
The History and Physical Examination:
Comprehensive or Focused?
Comprehensive Assessment
 Is appropriate for new patients in office or
hospital
 Provides fundamental and personalized
knowledge about patient
 Strengthens the clinician-patient relationship
 Helps identify or rule out physical causes related
to patient concerns
 Provides baselines for future assessments
 Creates platform for health promotion through
education and counseling
 Develops proficiency in the essential skills of
physical examination
Focused Assessment
 Is appropriate for established
patients, especially during routine or
urgent care visits
 Addresses focused concerns or
symptoms
 Assesses symptoms restricted to
a specific body system
 Applies examination methods
relevant to assessing concern or
problem as precisely and carefully as
possible
29

30. Marc Imhotep Cray, M.D.
Summary of the Diagnostic process
30
Step 1: Take a History: Elicit symptoms and a timeline; begin a
problem list.
Step 2: Develop Hypotheses: Generate a mental list of anatomic
sites of disease, pathophysiologic processes, and diseases that might
produce the symptoms.
Step 3: Perform a Physical Examination: Look for signs of the
physiologic processes and diseases suggested by the history, and
identify new findings for the problem list.
Step 4: Make a Problem List: List ALL the problems found during the
history and physical examination that require an explanation.

31. Marc Imhotep Cray, M.D.
Summary of Diagnostic process(2)
31
Step 5: Generate a Differential Diagnosis: List the most probable
diagnostic hypotheses with an estimate of their pretest probabilities.
Step 6: Test the Hypotheses: Select laboratory tests, imaging studies,
and other procedures with appropriate likelihood ratios to evaluate
your hypotheses.
Step 7: Modify Your Differential Diagnosis: Use the test results to
evaluate your hypotheses, eliminating some, adding others, and
adjusting the probabilities.
Step 8: Repeat Steps 1 to 7: Reiterate your process until you have
reached a diagnosis or decided that a definite diagnosis is neither
likely nor necessary.

32. Marc Imhotep Cray, M.D.
Summary of Diagnostic process(3)
32
Step 9: Make the Diagnosis or Diagnoses: When the tests of your
hypotheses are of sufficient certainty that they meet your stopping
rule, you have reached a diagnosis.
If uncertain, consider a provisional diagnosis or watchful waiting.
 Decide whether more investigation (return to Step l), consultation,
treatment, or watchful observation is the best course based upon
the severity of illness, the prognosis, and comorbidities.

33. 33
THE END
See next slide for links to tools
and resources for further study.

34. Marc Imhotep Cray, M.D.
Sources and Further Study:
34
Cloud Folders
Introduction to Clinical Medicine I (ICM-1)
Introduction to Clinical Medicine II (ICM-2)
Bate’s Guide to the Physical Examination and History Taking, Lynn Bickley (with Video)
DeGowin’s Diagnostic Examination, 9th Ed. Richard DeGowin,et al.
Textbook of Physical Diagnosis: History and Examination, Mark Schwartz. (with Video)
A Practical Guide to Clinical Medicine, Charlie Goldberg and Jan Thompson.
(A PDF version of the website compiled by this presenter.)