The document discusses the components and process of taking a patient's physical exam and health history. It describes taking an initial health history that includes the patient's chief complaint, present illness, past medical history, family history, social history, and review of systems. The physical exam includes assessing the patient's general appearance, vital signs, and performing a comprehensive or problem-focused examination of each body system using inspection, palpation, percussion, and auscultation. Proper documentation of subjective and objective exam findings is also emphasized.

1. Physical Exam & History Taking

2. Why we perform P/E & Health Hx
• Identify problem symptoms & abnormal
findings
• Linking findings to an underlying process of
pathology
• Establishing and testing a set of explanatory
hypotheses

3. Component of the health history
• Identifying Data or Initial Information
• Chief complaint
• Present illness
• Past history
• Family history
• Personal and social history
• Review of the system

4. Components of adult health history
• I- Initial information
1. date & time of history
2. identifying data & source of history or
referral
3. reliability; information should be
documented if relevant
( memory, trust, mood)

5. Continue
• II-Chief complaint: the one or more symptoms
or concerns causing patient to seek help.
• Quote patient own words.
• E.g. “my stomach hurt me & I feel sick”
• E.g. “ I come for my regular check up”

6. Continue
• III- present illness: a complete &
clear description of problems that
patient seeking help

7. Characteristics of present illness
• Location. Where is it? Does it radiate?
• Quality. What is it like?
• Quantity. How bad is it?
• Timing. When did it start? How long does it last?
How often does it come
• Setting in which it occurs including environment,
personal activities & others
• Remitting or exacerbating factors
• Associated manifestations

8. • Present illness should reveal pt. responses to
his symptoms & what effect the illness has
had on pt. life
• Medications, allergies, tobacco, alcohol should
also be noticed, …. risk factors.
• For patient with more than one symptom,
each symptom merits own paragraph and full
description.

9. • IV- past history includes
• Childhood illnesses; mumps, measles,…..
• Adulthood illnesses; Medical, surgical,
obstetric, psychiatric,
• Health maintenance(immunizations &
screening tests)

10. • V- family history
• Outlines age, health, & cause of death
of parents, siblings & grandparents
• Documents presence or absence of
specific illnesses in family e.g. HTN

11. • VI- personal & social history
• “Pt. personality, interest, source of
support, coping styles, strengths, fears.
• occupation, significant others, level of
education, source of stress, leisure's
activity, job Hx and concerns, ADL, &
others.

12. • VII- Review of body systems
• Document presence or absence of common
symptoms related to each major body system
• It is part of subjective data
e.g.. Head, headache, head injury
– Eyes: visions, glasses, contact lenses, pain,
redness, excessive tearing, double or blurred
vision
– Ears: hearing, tinnitus, infection, discharge

13. Physical Exam Approach
• There are two approaches of P/E
• 1. comprehensive P/E conducted for most new
pts being admitted to hospital
• 2. problem oriented or focused: segments of
examination
• P/E begin with general survey & V/S
• General survey; height, weight, gait,
groom,…..others.

14. Physical Assessment Methods
• Inspection
• Palpation
• Percussion
• Auscultation

15. Inspection
• Assessment
process during
which the nurse
observes the client

16. Inspection
• Initial contact and ongoing
• General appearance, body language
• Examine: color, size, shape, position, symmetry
(compare like areas)
• Systematic unhurried approach
• Expose part, respect privacy
• Know “normals”
• Observe “normals/abnormals”

17. Palpation
• The use of the hands and the sense of touch
to gather data or tactile pressure from the
palmar fingers or finger pads to assess areas
of skin elevations , depression and others.

18. Palpation
• Detects texture, temp, movement,
pain, moisture
• Short fingernails, warm hands
• Gentle approach

19. Percussion
• Tapping of various
body organs and
structures to
produce vibration
and sound.

20. Auscultation
• The act of
listening to
sounds within the
body to evaluate
the condition of
body organs
• (stethoscope)

21. Equipment
• Stethoscope
• Pen light
• Blood Pressure Cuff
• Thermometer
• Watch with second hand

22. Preparing for Physical Examination
• Reflect on your approach to the patient
identify self, be calm, organized, competent
• Adjust the lightening and the environment
• Make the patient comfortable; Minimize how
often you ask the patient to change position.
• Check your equipment
• Choose the sequence of examination

23. Subjective and Objective data
Subjective data Objective data
What the patient tell you
• The history
• Chief complain
• Review of the system
What you detect from
the physical examination
• All the physical
examination findings
are objective data

24. Recoding findings
• Purposes
• 1. organize information from Hx &P/E
• 2.communicate patients clinical issues to all
members of health team
• There is a special format which document
findings
• Information should be taken as soon as
possible
• The order of writing should be consistence

25. • The degree of details should be pertinent to
the subject or problem but not redundant

26. Principles of Documentation
• Timing: as soon as
possible
• Confidentiality
• Signature
• Accuracy
• Sequence
• Appropriateness
• Completeness
• Standard
Terminology
• Legal Awareness

27. Interviewing
• Purposes of Interview
• 1. to establish a trusting & supportive
relationship
• 2. to gather information
• 3. to offer information
• The process of interviewing pt requires a
highly refined sensitivity to pt feelings &
behavioral cues

28. • The interviewing process is much fluid &
demands effective communication &
relational skills
• It requires not only knowledge of data you
need to obtain but also the ability elicit
accurate information & interpersonal skills
that allow you to respond to pt feelings &
concerns

29. The Approach of Interview
• I. getting ready
• A. taking time for self reflection
Aware of our own values, assumptions, biases
Being respectful and open for differences
• B. reviewing the chart
• C. setting goals for the interview
• D. reviewing your clinical behavior & appearance
• E. adjusting the environment
• F. taking notes

30. • II. The sequence of interview
• 1. greeting pt & establish rapport
• 2. Establishing an agenda
there is specific goals in mind for interview
use time effectively
obtain C/C
Begin with open ended questions
“ how can I help you “
“ what concerns bring you here today”

31. • 3. inviting pt story
use verbal & nonverbal cues
“nodding head” “saying ah huh” “go on”
“tell me more” “ what else”
Listen to pt without interruption

32. • 4.Identifying and responding to patients
emotional cues
• 5. Expanding & clarifying pts story
• Guide pt into elaborating areas of history
• Try to clarify attributes of each symptom; OLD
CARTS (Onset, Location, Duration, Character,
Aggravating/Alleviating factors, Radiation,Timing,
Severity)

33. • or OPQRST; Onset, Palliating factors/ provoking
factors, Quality, Radiation, Severity/ Site, Timing
• Use language that is understandable& appropriate to
pt
• Try to use pts words and avoid technical ones
• 6. Generating and testing diagnostic hypotheses
• Symptoms- diagnoses?
• Yes/no ROS

34. • 7.Creating a shared understanding of the
problem
• We should ask pt. several questions about his
perception of illness
• It includes pt. thoughts or ideas about nature& cause
of problem
• Pt. feelings including fears or concerns about the
problem
• Pts. Expectations of health care
• The effect of problem on his life, function & others

35. • Example (about pain)
• Nurse; has anything like this happen to you or
your family before?
• Pt; I was worried that I might have
appendicitis. My uncle died of a ruptured
appendix

36. • 8. negotiate a plan
• It gives basis for planning further evaluation (
P/E, lab test, consultation) & negotiating a treating
plan
• 9. planning for follow up and closing
• Let pt know the end of interview is approaching to
allow time for the patient to ask questions
• Make sure pt understand the mutual plans you have
developed

37. • Example
• “we need to stop now. Do you have any
questions about what we covered”
• As you close review future evaluation,
treatment, & follow up.

38. III-building a therapeutic relationship; The
techniques of skilled interviewing
• 1. building the relationship; by active listening
• 2. using guided questions;
a. moving from open ended to focused questions
b. using questioning that elicit a grade response
c. asking a series of questions
d. offering multiple choices for answers
e. clarifying what the patient means
f. encouraging with continuers
g. using echoing

39. III-building a therapeutic relationship
• 3.nonverbal communication
• 4.empathic responses (acknowledge pt feelings)
• 5.Validation (acceptance of feeling)
• 6. reassurance
• 7.partnering; to make explicit your desire to work
with them in ongoing way
• 8. summarization
• 9.transition
• 10. empowering patient;
• Pt should be confident by himself

40. IV- Adapting your interview to specific
situations
• The silent patient
• The confused patient
• The talkative patient
• The crying patient
• The angry and disruptive patient
• Patients with low literacy
• Patients with impaired vision/ hearing/
• Patients with limited intelligence

41. V- Sensitive topics that call for specific
approach
• Guidelines for broaching sensitive topics (
abuse of alcohol or drugs, sexual practices,
death, violence, ….etc)
• 1. be non judgmental
• 2. explain why you need to know certain
information
• 3.find opening questions for sensitive topics
and learn the specific kinds of data needed for
your assessment

42. • Examples;
• “what do you like to drink”
• “have you ever had a drinking problem of
alcohol”
• “have you ever used any drugs other than
those required for medical reasons”
• “when was the last use”
• “how often substance use”

43. General Survey
• 1. Apparent state of health
• 2. Level of consciousness
• 3. Signs of distress
• 4. Height and build
• 5. Weight
• 6. Skin color and obvious lesions
• 7. Dress, grooming, and personal hygiene
• 8. Facial expressions
• 9. Odors of body and breath
• 10. Posture, gait, and motor activity