GENERAL HISTORY TAKING & PHYSICAL EXAMINATION

HISTORY TAKING &
GENERAL PHYSICAL
EXAMINATION
Dr. ANIKET A. SHILWANT
Assistant Professor
Dept. Of Kriya Sharir
GJPIASR, CVM University

One of the first duties of the physician is to
educate the masses not to take medicine.
- Sir William Osler
Dr. Aniket A. Shilwant, GJPIASR

CLINICAL EXAMINATION
HISTORY
TAKING
EXAMINATION OF PATIENT
GENERAL EXAMINATION
(GE)
SYSTEMIC
EXAMINATION
(SE)
GIT + RS + CVS
+ NS

HISTORY TAKING
Step by Step Guide to Comprehensive Adult Health History:
1. Personal History – Data identification, Source of History
2. Chief Complaint(s) & Present Illness
3. Past History
4. Family History
5. Personal and Social History
6. General Examination
7. Systemic Examination

1. Data Identification & Collection – Full Name, Age, Gender,
Occupation, Marital Status
2. Source of history –
Usually patient
Family member / Friend / Relatives / Stranger
Referral letters
Past Medical records
HISTORY TAKING

PERSONAL HISTORY – BIODETAILS
 Name – Speech, Orientation
 Age – Age related diseases
 Sex – Sex related diseases
 Height, Weight – Nutrition related, Endocrinal diseases
 Occupation – Skin, Soft tissue diseases, Occupation related diseases
 Socio-Economic, Financial status – Hygiene related, Social Stigma
 Marital status – Hormonal changes, Psychological impacts

CHIEF COMPLAINTS (CC) & PRESENT ILLNESS (HPI)
1. Reliability
2. Validity / Significance
3. Orientation
4. Onset & Duration
5. Pattern
6. Associated symptoms
7. Relevance with recent events
HPI – May include medications, allergies, habits of smoking and alcohol, which are
frequently pertinent to the present illness.
CC & HPI –
 Sequence
 Severity
 Duration

PAST MEDICAL HISTORY (PMH)
 Childhood illnesses
 Adult illnesses with dates
 Medical – Sub branches
 Surgical
 Gynecologic & Obstetrics – Menstrual
 Psychiatric
 Health preservation practices – Immunizations, Health check ups,
Screening tests, Lifestyle issues and modification and other safety
measures

FAMILY HISTORY (FH)
 Age and health history outline of – blood related persons, parents,
grandparents, siblings, etc.
 Medical records of Hereditary diseases
• Blood related diseases
• Metabolic diseases
• Malignancies
• Lifestyle related diseases
• Endocrinal diseases

PERSONAL (PH) & SOCIAL HISTORY (SH)
Educational level
Lifestyle
Habits / Addiction
Religious / Spiritual beliefs
Personal interests
Social approach

SYSTEMIC EXAMINATION PROTOCOL
INSPECTION
Observation, noting the findings which are deviated from the standard.
PALPATION
Touching or feeling the part or organ of body.

SYSTEMIC EXAMINATION PROTOCOL
PERCUSSION
Listening to echo after creating a set of vibrations in the underlying tissues of body.
AUSCULTATION
Listening to body sounds using instrument to assess the functioning of organs.

EXAMINATION PROTOCOL
1. Inspection – Observing any body part manifesting abnormality by ample use of sensory senses such as –
vision, hearing, and smell but not by touch. This is useful to extract information in terms of color,
location, movement, symmetry, odor, patterns, sounds and other technical specification.
2. Palpation – Only sensory sense used for this is Touch. Touching different parts of body manifesting
abnormality with varying degrees of pressure and observing the consistency (firm / soft / tenderness),
texture, pain and other sensation developed from the foci.
3. Percussion – It involves tapping on the particular body part by direct and indirect methods. The tapping
over body parts should be quick and sharp inducing vibration notes towards the underlying organ or
structure and collects the same vibration when rebound backwards. It is helpful to determine the shape,
position of organ; also it determines state of inner content of an organ.
4. Auscultation – In this, we can listen various sounds produced from the internal body structures using
stethoscope. Such as – lungs sounds, heart sounds in adults and in fetus, intestinal sounds, record BP.

GENERAL EXAMINATION
APPEARANCE
 Age-Height-Weight
 Body built
 Growth
 Nutrition
 Orientation
POSTURE
 Lordosis – Forward bending or extra anterior curvature of vertebral column
Kyphosis – Backward bending or extra posterior curvature of vertebral
column
 Scoliosis – Sideward bending of vertebral column

GAIT
 Hemiplegic Gait (Spastic gait) – Unilateral weakness on the affected side. Subject in this case
will hold one arm and literally drags affected leg. This is termed as – Spastic gait.
 Diplegic Gait (Scissors gait) – In such cases, one may see dragging of both legs with scraping the
toes. This is termed as – Scissors gait. The crisscross motion resembles closing and opening of
scissors.
 Neuropathic Gait (Steppage Gait) – The subject in this type of gait attempts to lift leg high
while walking instead of dragging on the floor which appears to be foot drop due to weakness of
foot dorsiflexion. In this gait the toes of a person tries to catch the ground this is called as –
Steppage gait.
 Cerebellar gait (Ataxic Gait) - This gait appears to be clumsy, subject walking on wide base with
feet widely placed. Subject is unable to walk on a single line instead starts deviating to left and
right sides manifesting zigzag pattern of walking. This is called as – Ataxic gait. It is mostly seen
in Cerebellar lesions.

GAIT
 Parkinsonian Gait (Festinating gait) - As mentioned, this type of gait is seen in
Parkinsonism. In this type the subject moves forward rapidly with short shuffling steps.
It appears so that subject is trying to catch up with the center of gravity. This is called as
– Festinating gait. This is seen in diseases occurring as a result of adverse effects from
drugs or hormones. Eg. Parkinsonism.
 Sensory Gait (Stamping gait) - The subject in this type of gait raises the foot suddenly
and brings it down to ground rapidly appearing like a stamp. This appears due to lack of
sensory feedback from proprioceptors to the brain. This is called as – Stamping gait. It
is seen in Tabes dorsalis, peripheral neuropathy as in uncontrolled Diabetes.
 Waddling gait – In this type the body usually swings backwards with prominent lumbar
lordosis with feet placed widely apart and body sways sideways while walking. It
appears like a duck. This is called as – Waddling gait. It is seen in muscular dystrophies
affecting pelvic, hip and thigh muscles.

FACE & SPEECH
 Note symmetry of face, wrinkles over face
 Color, skin lesions over face
 Voice tone and its abnormality
 Type of Speech

SKIN
Color
 Pallor – Pale skin
 Icterus – Yellowish skin hyperbilirubinemia
 Cyanosis – Bluish black coloration of skin
Texture
 Skin Tone
 Eruptions, Pigmentations

CONJUNCTIVA TONGUE
CREASES OF PALM NAIL BEDS
PALLOR

ICTERUS CYANOSIS

HYPERPIGMENTATIONS HYPOPIGMENTATIONS

NECK
 Movements – Flexibility, Stiffness
 Range & Ease of movements
 Extra growth
 Skin at folds
 Lymph glands
 Lymphoadenopathy – Inflammatory, Degenerative, Neoplastic

ENLARGED LYMPH NODES, LYMPHOPATHY, ADENOPATHY
NECK STIFFNESS
ACANTHOSIS NIGRICANS

CHEST
 Shape – Curvature and any deformity of spine at the back
 Rate of breathing
 Type of breathing
 Odor of breath
 Sweet – Diabetes, Ketosis
 Ammoniac – Uremia
 Bad breath (Hallitosis) – Poor oral or dental hygiene

FUNNEL & BARREL CHEST

PECTUS EXCAVATUM
PECTUS CARINATUM

ABDOMEN
 Shape – Flat, Globular, Scaphoid
 Texture – Scars, Growth or any other deformity
 Pulsations
No bowel sound – Silent Abdomen – Paralytic Ileus*
F’s –
 Fat – obesity
 Fluid – ascites
 Flatus – abdominal distension
 Fetus – pregnancy
 Feces – severe constipation with fecoliths
 Fibroid – Ovarian enlargement

SCARS OVER ABDOMEN
PROTRUBERENT
ABDOMEN
CONCAVE
(SCAPHOID)
ABDOMEN

EXTREMITIES
 Skin complexion
 Skin texture – Wound, Injury, Scars, Bruises, Contusions
 Skin & Muscle tone – Hypotonic, Hypertonic
 Muscle strength
 Muscle movements – Tremors
 Pigmentations, Cyanosis
 Clubbing of Fingers – Iron deficiency anemia, Congenital heart disease,
Respiratory tract diseases as like Bronchiectasis, Emphysema.

ABRASIONS BRUISES
CONTUSIONS
ULCERATIONS

CLUBBING OF FINGERS
SCHAMROTH SIGN

VITALS
VITAL SIGNS – T, P, R, BP, SpO2
 T – Temperature
 P – Pulse
 R – Respiratory rate
 BP – Blood pressure
 SpO2 – Oxygen Concentration

Thank You All !!!
Dr. Aniket A. Shilwant
Assistant Professor
Department of Kriya Sharir
GJP-IASR, CVM University
Email –
ayuraniket18@gmail.com
http://ayugjac.edu.in/Staff_CV.aspx?dl=dn3Mja19480dn3Mja19
http://scholar.google.co.in/citations?user=636K2sMAAAAJ&hl=en
https://www.researchgate.net/profile/Aniket_Shilwant
36

GENERAL HISTORY TAKING & PHYSICAL EXAMINATION

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