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history taking and physical examination.pptx
1. Introduction to History Taking and Physical
Examination
Dr. Samuel Shimelis (MD)
4/24/2024 DBU, COLLEGE OF MEDICINE, DEPARTMENT OF
INTERNAL MEDICINE
2. Outline
• Introduction
• History taking
• Physical examination
• Techniques of skilled Interviewing
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
3. Objectives
• To explain components of comprehensive History taking
• To discuses Physical examination components
• To list Techniques of skilled Interviewing
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
4. Introduction
• In care of the suffering one needs to have technical skill and human
understanding in addition to scientific knowledge
• Skilled interview is mandatory to illicit important information relevant
to current illness
• Physical examination without proper history is like looking for an
object in darkness
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
5. cont...
• laboratory should not dictate over meticulous clinical evaluation
• careful communication, observation and study of the patient can not
be replaced by investigations
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
6. The Comprehensive health history
• Date and Time of History
• Identifying Data
• Age, gender, marital status, education, occupation, religion,
residence area, date of admition, and bed number
• The source of history
• Referral
• Mode of arrival
• Reliability: should be documented if relevent. e.g. “ the patient is
vague when describing symptoms and unable to specify details”
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
7. cont...
• Chief complaint (s)
• Should be documented in patient’s word
• It could be one or more
• It Has to be time bounded
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
8. cont...
• History of present Illness
• Elaboration of HPI should be chronological , complete and clear
• The principal symptoms should be well characterized with
descriptions of
• location, quality, quantity of severity, timing( onset, duration
and frequency ), aggravating and relieved factors , associated
symptoms
• It is also important to include “ pertinent positives and pertinent
negatives and Risk factors
• Use open ended question
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
9. cont...
• medication, smoking, alcohol drinking habit, allergy should be
assessed
• Past History:
• childhood illness: MMR, whooping cough
• medical, surgical, gyn/obs, and psychiatry
• Family History:
• mother, father, sibling, grandparents, children, grandchildren
• family hx chronic illness
• age, health, if death ( date, cause, age at time of death)
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
10. cont...
• Personal and Social History
• It includes the patient’s personality and interests, sources of
support, coping style, strengths and fears
• It should include the childhood time, education, occupation, life
style habits, home situation and diet
• Social interaction history
• Baseline level of function in elderly individuals
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
11. cont...
• Review of Systems
• Start with fairly general question then shift to specific question
about systems that may be of concern
• e.g. how are our ears and hearing?.. any trouble with your
heart... how about your breath and lung....
• It may uncover problems that the patients has overlooked,
particularly in areas unrelated to the present illness.
• Significant health events ( major illness or parent’s death) need
evaluation and should be included in HPI
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
12. cont...
• Systemic Review Components
• HEENT :
• Head: headache, injury, dizziness, lightheadedness
• Eye: visions status, glasses or contact lenses, pain, redness,
excessive tearing, blurring of vision
• Ears: hearing status, tinnitus, vertigo, ear aches, discharge
• Nose and Sinuses: discharge, itching nose bleeding, sinus
trouble
• Throat ( or Mouth and pharynx): toothache , bleeding gums,
dentures
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
13. cont...
• LGS: lumps , pain, or discomfort, nipple discharge
• RS: cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy
• CVS: chest pain, hx of HTN, rheumatic fever, palpitation, dyspnea,
orthopnea, PND, edema
• GIS: d/t swallowing, heartburn, appetite, nausea, vomiting, change
in bowel movement, rectal bleeding, constipation, diarrhea,
abdominal pain, belching , distention, jaundice
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
14. cont...
• GUS: urinary frequency, polyuria, dysuria, hematuria, flank pain,
lower abdominal pain, ulcer, discharge, swelling, hesitancy, dribbling,
testicular pain, mass, menstrual hx
• MSS: muscle or joint pains, stiffness , backache, d/t moving the limb
• INT: rashes, lumps, sores, itching, dryness, color change, changes
in hair or nails
• CNS: seizures, weakness, paralysis, numbness, loss of
consciousness, tingling or “pins and needles, tremors
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
15. Cont…
Example of patient’s History
• ID: This is Mrs Xx a 35 years old orthodox Christian farmer from keyet
admitted on yekatit 27/2016 E.C in IMD on bed no 4
• Source of referal: self referal
• Mode of arrival: on foot
C/C: Abdominal pain
• HPI: This is a 35 years old female patient present with crampy periumblical
abdominal pain associated with this she has also mucus and blood mixed
watery stool 6-8 times/day for the past 2 days, tensimus, high grade
intermittent fever, abdominal bloating and decreased appetite. She has taken
unspecified PO medication for abdominal pain but has no improvement
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
16. Cont…
Otherwise:
• She has no hx nausea or vomiting, has no hx of passing faeces or flatus, has
no dysuria, urgency or frequency, she has no previous abdominal surgery,
has no hx of smoking and alcohol consumption
•How do you see the given history????
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
17. Cont…
E.g.
ID: This is Mrs. Xx a 35 years old female orthodox Christian farmer who has no formal
education from keyet admitted on yekatit 27/2016 E.C at 1 NLT in IMD on bed no 4
Source of History: herself
Source of referral: self referral
Mode of arrival: on foot
Reliability: seems reliable
• C/C: Abdominal pain of 3 days duration
• HPI: This is a 35 years old female patient present with gradual onset moderate crampy
periumblical abdominal pain of 3 days duration with no radiation and aggravating and
reliving factor. associated with this she has also mucus and blood mixed watery stool of 6-8
times/day for the past 2 days, tensimus, high grade intermittent fever, abdominal bloating
and decreased appetite. She has taken unspecified PO medication for abdominal pain but
has no improvement. She usually use spring water for drinking and cooking, she also lives
in a family of 6 members and there is similar cases in her village
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
18. Cont…
• Otherwise:
• she has no hx nausea or vomiting, has no hx of passing faeces or flatus, has no dysuria,
urgency or frequency, she has no previous abdominal surgery, has no hx of smoking
and alcohol consumption
• Family hx: her mother and father are 59 and 67 years old and health respectively, has
no family hx DM/HTN or renal disease
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
19. Physical Examination Approach
• General Appearance:
• Acute, chronic, acute on chronic
• Grooming, personal hygein, way of talking, walking, facial
expressions, weight, posture, gait affect,
• Vital signs: PR, RR, T, BP, PSO2, weight and height
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
23. cont...
• HEENT:
• Head: hair , scalp, skull, face
• Eye: conjunctiva, sclera, the eyelids, opthamoloscope
examination
• Ear: pinna, tragus, mastoid, otoscope examination, weiber’s and
rinnes test
• Nose and throat: nostrils, nasal septum, nasal bone, sinus
palpation, lips, tongue, gum, teeth, palates tonsils and pharynx
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
24. cont...
LGS: lymph node palpation, thyroid, breast, tastes
RS:
• Inspection: cyanosis, breathing, intercostal , subcostal
suprasteranal retraction, chest symmetrical, scan, shape of the
chest,
• Palpation: tenderness, TF, chest expansion,
• Purcussion: dullness, diaphram excursion
• Ausculation: breathing sound, added sound
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
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• CVS:
• Venous: raised JVP, distended neck vein
• Artery: PR, R-R or R- femoral delay
• Precordial examination:
• Inspection: active or quite precordial, AP, PMI
• Palpation: valvular areas, heave, thrills
• Auscultation: s1 and s2 sound, murmur, s3 or s4 sound
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
26. cont...
• Abdomen:
• Inspection: the shape of the abdomen, movement respective of
breathing, any scar, shape of umbilicus, distended vein, visible
pulse of peristalsis, hernia sites
• Palpation:
• Superficial: tenderness or mass
• Deep: tenderness, mass, organomegaly
• DRE
• Percussion: tympani or dullness, TVLS, sign of fluid collection
• Auscultation: bowel sound, bruits, venous ham
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
27. cont...
• GUS:
• Inspection: swelling, ulcer, fissure, discharge
• Palpation: CVAT , mass, PV examination PVR examination
• MSS:
• Look: swelling, deformity, scar, fracture, angulation, bleeding,
• Feel: hotness, tenderness, crepitation, mass
• Move: range of motion
• Measure: the length, discrepancy of the limbs
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
28. cont...
• INT: lesions, lumps, discharge, capillary refill
• NS:
• Mental status: COTPP
• CN
• GCS
• Motor: tone, power
• Reflex
• Sensory: touch, pain, pressure, proprioceptive
• Coordination
• Meningeal sign
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
29. Cont…
• E.g. for reporting physical examination result
• This is a 35 years old female patient who present with moderate crampy
periumblical abdominal pain with blood and mucus mixed watery diarrhoea
of 03 days duration and high grade intermittent fever of same duration;
• On physical examination GA: she is acutely sick looking V/S: PR: 102bpm
, T: 38.7 c , BP: 80/60mmHg ,RR: 28bpm , Pso2: 94 % with ATA ,
HEENT: she has pale conjunctiva , Non icteric sclera, dry buccal mucosa,
no sunckening of eye ball, Abdomen: flat abdomen, direct tenderness on
the umbilical area, no organomegaly, no sign of fluid collection, GUS: no
CVAT, INT: capillary refill is <3 second, hot extremity, no palmar pallor ,
CNS: she is COTPP, GCS is 15/15
• Assessment: ?sepsis of GI focus + mild dehydration 2ry to GI loss
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
30. After History and physical examination
completed
• Investigations
• Laboratory: CBC, stool, urinalysis, OFT( RFT, LFT, TFT), H-
pylori, RF, uric acid, widal, weil feilx, BF, RBS…
• Imaging: U/S, CXR,CT,MRI, upper GI endoscopy,
• Pathology: FNAC, excisional biopsy, peripheral morphology,
bone marrow aspiration, bone marrow biopsy
• Management: outpatient vs inpatient
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
31. Techniques of skilled Interviewing
• Active listening
• Adaptive questioning
• Non verbal communication
• Facilitation
• Echoing
• Empathic responses
• Validation
• Reassurance
• Summarization
• Highlighting transitions
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
32. References
• Bate’s guide to physical examination and history taking
DBU, COLLEGE OF MEDICINE, DEPARTMENT OF INTERNAL MEDICINE
