Medical & public Health students

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PHYSICAL DIAGNOSIS
COMPONENTS
-HISTORY TAKING
-PHYSICAL EXAMINATION
Dr. Adanwali Hassan Ahmed
Rn-Mw, Medical doctor (MD), Health Officer
(HO) Gyn/Obest

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HISTORY TAKING
Objectives
1.To clarify about clinical evaluation of a
patient.
2. To revise on basic techniques of Hx
taking.
3. To revise on contents & relevance of all
components of comprehensive health
history.
reorganize

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Clinical evaluation
• Comprises of health HX & P/E
• Core of patient evaluation
• Made based on Hx taking & P/E skills
Importance of clinical evaluation
70% - 80% of diagnosis is made by it.
Guides next step or it is base for investigation
based evaluation.

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THE HEALTH HISTORY
• Is a record of clinical event.
• Concerned with symptoms.
 Symptoms: are subjective complaints noted
& told by a patient.
- E.g. Cough, Chest pain, Shortness of
breath, Vomiting, Diarrhea, Constipation,
Fever, Loss of appetite, Loss of weight.
• Guides physical examination.

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Hx taking/Conducting Interview
 Has four main components:
1. Greeting the patient and Establishing
Rapport.
2. Skilled Interview (supportive interview).
3. Taking Notes.
4. The Closing.

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1. Greeting the patient and
establishing Rapport:
• Greet the patient and introduce yourself.
• Maintain Confidentiality.
• Arrange the room.
• Give your undivided attention.
2. Making skilled Interview:
• Interview should be more flexible, focused &
problem oriented.
• Should be more fluid & will follow patients
leads & cues. (A stimulus that provides information about
what to do)

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uses d/t options to clarify patients story.
• Directed Questioning; from general to specific
& should be open ended.
N.B avoid leading questions.
• Moving from open-ended to focused questions
• Questioning to elicit graded response
• Asking series of questions one at a time
• Offering multiple choices for answer
• Clarifying what the patient means
• Echoing
a. Adaptive Questioning: based on patients
verbal and non verbal cues

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b) Adaptive listening: process of fully
attending what a patient is communicating
-it needs practice.
c) Facilitation: maintaining the flow of the
patient’s story.
-Made by actions ( nodding head, leaning
forward) or words (Go.. on. ”I’m listening’’)
d) Echoing: simple repetition of patient’s word
e) Empathic Response: sharing patient’s
feelings & responding accordingly.

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f) Validation: making the patient feel his/her
emotions are understandable
g) Reassurance: should be made at the end.
h) Summarization: giving summery of the
story.
-It indicates to the patient that your listening.
-Helps to know what you know & don’t know.
-Allows to organize clinical reasoning

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3. Taking Notes:
-Jot down short phrases, specific dates or
words.
-Don’t let note taking distract you from the
patient.
-Keep good eye contact.
4. The Closing
-A time to encourage the patient to discuss any
additional problems, or to ask any question.
-But, don't answer questions if you aren’t sure.

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Components of Comprehensive
Health History
• Listed in standard format of CASE REPORT.
• Structure patient’s story & format of written
document.
• N.B - order should not dictate sequence of
interview (technique of history taking should be
flexible)
• Preferably organization of information in to
formal written format should be after the
interview & examinations are completed.

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Order of Case Recording
1. Identification of the patient
2. Previous Admissions
3. Chief complaints
4. History of the present Illness
5. Past Illness
6. Functional Inquiry ( System Review)
7. Personal &Social History
8. Family History

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1. Identification of the patient
- Date -Time
- Full Name - Date of Admission
- Age & Sex -Ward
- Address - Bed No
- Occupation
- Religion
2. Previous Admissions; list of
hospitalization in the order they occurred.
- Specify the date, name & location of the
hospital.
- The disease that led to admission & the
outcome.

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3. Chief complaint (s)
Is the main complaint that brought the patient to seek
medical care.
Should be simple, brief & recorded with duration of each
symptoms using patients word.
If there are >2 C/C ,should be listed in order of
occurrence.
The question can be put as “what is the main problem
that has brought you to hospital?”
e.g.= Shortness of breath / 3 weeks
= Not Dyspnea
= Chest pain / 1 week

15. THE SEVEN ATTRIBUTES OF A SYMPTOM
1.Location: Where is it? Does it radiate?
2.Quality: What is it like?
3.Quantity or severity: How bad is it? (For pain, ask for a
rating on a scale of 1–10.)
4.Timing: When did (does) it start? How long did (does) it
last? How often did (does) it occur?
5.Setting in which it occurs: Include environmental
factors, personal activities, emotional reactions, or
other circumstances that may have contributed to the
illness.
6.Remitting or exacerbating factors: Does anything make
it better or worse?
7.Associated manifestations: Have you noticed anything
else that accompanies it?

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4. History of present Illness
• It is detailed description of the chief complaint
in relation to its mode of onset &development
of illness in chronological order.
• Details of the chief complaint should include;
1. Date of onset:- it is often useful to start the
HPI with a phrase “the patient was perfectly well
until…” from then on ,the development of signs &
symptoms, expressed as chief complaint, should be
traced in detail to the present time.
2. Mode of onset: course & duration
- Sudden/ gradual
- Intermittent/ persistent
- Insidious
- Steady or increasing in severity

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3. Character (elaboration or analysis of
symptoms)
• Examples
I. common complaints=
a. Pain (PQRST):
-Place (location)
-Quality (dull aching, sharp,burning or
stabbing)
-Radiation
-Severity (mild ,moderate, sever)
-Temporal
b. Fever – Grade (low/high)
_Course (Intermittent/Persistent)

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II. Common cardio-respiratory symptoms=
a. Shortness of Breath
-How does it come on?/what degree of exertion produce it?
-Does it wake up the patient at night? (PND)
-Does the patient has to sit up/require more pillows while
lying supine? (Orthopnea)
b. Cough-
-Quality (Dry/Productive of sputum)
-Character (Hacking, Barking, Whooping)
-Timing (Morning/Nocturnal)
C. Sputum
-Color &Consistency (Serous, Purulent ,Mucoid, Frothy
& Mucopurulent)
-Odor (foul smelling, or Not)

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d. Palpitation
-What brings it ?(Exertion/Spontaneous)
-How long it lasts ?
e. Chest pain (PQRST)
f. Body Swelling (edema)
-Pattern of spread
-Time interval
III. Common GI & Renal Complaints=
 Vomiting-
-Pattern ( Projectile/ Non Projectile )
-Amount & Color (Bilious /Non Bilious )
-Content (Blood, Feculent, Ingested food)
-Frequency

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 Diarrhea
-Consistency & Color (watery, Bloody, mucous
containing)
-Frequency
 Abdominal Swelling (Distension)
-Initial Site
-Progression (rapid/gradual)
-Associated symptoms
 Urinary Symptoms
Urine---
-amount
-Color
-Frequency
-Pain during urination

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4. Aggravating & Relieving factors=
5. Course of symptoms=
-Persistent /continuous
-Short lived /constant
-Intermittent / on-off
-Steady /Increasing in severity
6. Effect of Treatment & Medications=
-Mode of treatment
Conservative (Life style modification)
Medications (Name,dose,Frequency)
Allergies
-Effect of Treatment

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7. Negative-Positive Statement=
• Includes completion of review of affected / suspected
system (s) ,& inquiry in to other related system, as
well as, medicinal, hereditary, environmental, &
other conditions related to the C/C.
 Aim is to construct DDX.
• Positive statements include
-Associated symptoms
-Risk factors
-Precipitating factors
-Predisposing factors
• Negative statements:-used to rule out DDx.

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8. Strength & Weight Changes=
Stated in the last paragraph of HPI.
Strength-how the patient came.
Weight change.

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5. Past illness
• Lists childhood illnesses
• Lists adult illnesses with dates for at least
four categories: Medical; Surgical; Obstetric/
Gynecologic; and Psychiatric
• Health maintenance practices such as:
immunizations, screening tests.

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6. Functional Inquiry(System Review)
• Is a detailed account of symptoms referable to
each system of the body.
• Can be made while examining the patient.
• Has the following main advantages:
Uncover problems that the patient overlooked--
-Gives Clear understanding of the HPI.
Allows to group important symptoms that need
to be considered with the present complaint.
It also helps to include important Negative
statement.
• Standard series of review of system Questions

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1. Head, Eyes, Ears, Nose, Throat (HEENT).
• Head: Headache, head injury, dizziness
lightheadedness.
• Eyes: Vision, glasses or contact lenses, last
examination, pain, redness, excessive tearing,
double vision, blurred vision.
• Ears: Hearing, tinnitus, vertigo,
earaches, infection, discharge. If hearing is
decreased, use or nonuse of hearing aids.

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• Nose and sinuses: nasal stuffiness, discharge, or
itching, bleeding per nose
• Throat (or mouth and pharynx):
= Condition of teeth, bleeding gums, sore tongue,
frequent sore throats.
2. Neck: Lumps, “swollen glands,” goiter, pain, or
stiffness in the neck.
3. Breasts: Lumps, pain or discomfort, nipple
discharge,
4.Respiratory: Cough, sputum (color, quantity),
hemoptysis, dyspnea, wheezing.

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5. Cardiovascular:
= Chest pain or discomfort, palpitations, dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, edema,
6. Gastrointestinal: nausea, vomiting, excessive
belching ,heartburn, loss of appetite, Pain up on
swallowing
• Change in bowel habits, (diarrhea constipation ) rectal
bleeding or black or tarry stools, hemorrhoids,,.
Abdominal pain passing of gas.
7. Urinary: Frequency of urination, Polyuria, Nocturia,
urgency, burning or pain on urination, Hematuria,
Hesitancy, dribbling.

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8. Genital. Male: discharge from or sores on the
penis, testicular pain or masses, history of sexually
transmitted diseases and their treatments.
Female: Gynecologic Hx:
 Vaginal discharge, itching, ulcer ,dyspareunia ,birth
control methods, & Exposure to HIV.
 Age at menarche; regularity, frequency, and duration
of periods; amount of bleeding, bleeding between
periods or after intercourse, dysmenorrhea, age at
menopause, menopausal symptoms, post menopausal
bleeding.
:Obstetric Hx
No of pregnancies, No & type of deliveries, abortions

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9. Integumentary System (skin, hair & Nail)
= Dry or Moist Skin, rashes, ulcers, hair
distribution & pigmentary changes, changes in
finger nails.
10.Musculoskeletal:
 Muscle or joint pains
 Stiffness, swelling, redness,
 Weakness, or limitation of motion or activity
backache.
 History of trauma.

31. Central nervous system:
• ƒ
History of fainting, seizures, weakness,
paralysis,
• Numbness or Loss of sensation, Tingling
sensation, Tremor Or other involuntary,
Movements,
• Insomnia, Poor Memory, Headache,
• Disturbance of speech,
• Disturbance of sphincter control,
Delusion, Hallucination, illusion, etc.

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7.Personal History
 Early development:-place of birth, child
hood development, activities, social & economic
status.
 Education
 Environment
 Social Activities &Habits
 Marital Status:- Health of husband (wife),
No
Of Children &their health.

33. 8. Family History
-father & mother’s: Age, health (if dead,
cause of
death)
-Siblings: list with ages, health (if dead, cause
of
death)
-Familial disease: (hypertension, Diabetes,
Asthma,TB & Migrian).
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PEDIATRIC HEALTH HISTORY
 Similarities with Adult
Health History:
In Basic Techniques of
history Taking.
In most of the contents of
comprehensive health
history.
 Differences from
Adult Health History:
History is obtained
Indirectly from care
taker.
The History has some
peculiar components
-Immunization Hx
-Nutritional Hx
-Developmental Hx

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Contents of pediatric history
1. Personal Details
2. Chief Complaint
3. History of Present Illness
4. Past Medical Illness
5. Family History
6. Immunization History
7. Nutritional History
8. Developmental History
9. Review of Systems

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1.Personal Details
• Patients Identification
-Name
-Age
-Sex
-Address
-Ward & Bed No
• Care taker’s
Identification
- Name
- Age
- Sex
- Occupation
- Religion
Importance of knowing Exact age of Pediatric
patient:-
 B/c of presence of age group Specific diseases.
B/c of assessment of growth & development is
based on age.
B/c used for Drug Prescription

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2. Chief Complaint
3. History of present Illness
4. Past Medical Illness:
Mother’s Prenatal, Labor & Delivery Hx.
Child’s Neonatal, Infancy & Childhood’s Hx.
Medical Illnesses: Measles, Pertussis, Mumps,
Chickenpox.
Surgical conditions & Medications.
5. Family History
o Social History: Housing, family size, Income, water
supply & waste disposal.
o Medical Hx: list of siblings & their health statu----
Familial Disease.

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6. Immunization History
When started?, types, time interval & route of
Administration.
Should be assed based on EPI Schedule:
At Birth OPV o and BCG
At 6 weeks OPV1,DPT1, Hep1, Hib1
AT 10 Week OPV2,DPT2,Hep2,Hib2
At 14 Week OPV3,DPT3,Hep3,Hib3
At 9 month measles

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7.Nutritonal History
Breast feeding (EBF/not, frequency & total
duration).
Complementary feeding ( when started? ,type
of meal, frequency & duration).
Exposure to sun Light.
Current diet (type & frequency).

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8.Developmental History
• Assessed based on the four Spheres of development
(Developmental Milestones) for that Particular age.
A. Gross Motor dev’t: includes control of head,
trunk & extremities.
B. Fine Motor dev’t: includes the dev’t of finger
movements.
C. Language dev’t: production of sounds, words,&
understanding others.
D. Social Dev’t: identification of objects,& persons
,ability to play with others.
9.Review of Systems

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