This document provides information on history taking and physical examination in healthcare. It discusses the importance of obtaining an accurate patient history through questioning to aid diagnosis. A physical exam involves inspection, palpation, percussion and auscultation of the body to evaluate overall health status. Key parts of the exam are assessment of the skin, head, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, back and genitalia. Common medical conditions and abnormalities that may be observed are also outlined.

1. HISTORY TAKING AND
PHYSICAL
EXAMINATION

3. INTRODUCTION
It is a process by which information
is gained by a physician by asking
specific questions to the patient
with the aim of obtaining
information useful in formulating a
diagnosis and providing medical
care to the patient.

4. IMPORTANCE OF HISTORY TAKING?
Obtaining an accurate history is
the critical first step in determining
the etiology of a patient's illness.
Diagnosis in medicine is based on-
Clinical history
Physical Examination
Investigations

5. HISTORY
PATIENT’S PROFILE
CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HSTORY
PAST SURGICAL HISTORY
FAMILY HISTORY
FAMILY TREE
MARITAL HISTORY
SOCIOECONOMIC HISTORY
ENVIRONMENTAL HISTORY

6.  PATIENT PROFILE
•Name
•Age/Sex
•DOB
•Religion
•Education
•Occupation
•Address
•Ward/Bed No.
•DOA
•Diagnosis

7.  CHIEF COMPLAINTS
• Complains of patient regarding present
Illness.
 HISTORY OF PRESENT ILLNESS
• Number of days patient is suffering from
signs and symptoms.
 PAST MEDICAL and SURGICAL HSTORY
• Any history of similar complaint in the
past.
• Other medical problems the patient has
or had any chronic disease present like
hypertension, diabetes etc.
• Past hospitalizations and past surgeries.
• Medications if any taken in the past
(dosage and duration)
• Allergies
• Pediatric: Birth history, Developmental
Milestones, Immunizations

8.  PERSONAL HISTORY
• Smoking history - amount,
duration and type.
• Drinking history - amount,
duration and type.
• Any drug addiction
• Sexual history if suspected STI.

9. FAMILY HISTORY
• Number of family members,
education any Heritable
illness. Current family health
status. Psychosocial disorders.
 FAMILY TREE

10.  MARITAL HISTORY
• Marital status
• Years of marriage
 SOCIOECONOMIC HISTORY
• Number of earning members in
family
• Total per-capita income

11. ENVIRONMENTAL HISTORY
• Type of House
• Water supply
• Electricity supply
• Ventilation
• Drainage
• Toileting

13. INTRODUCTION
A physical examination is an initial
evaluation for emergency care, for
routine screening to promote
wellness and preventive health care
measures or to admit a patient to
hospital or long term care facility.

14. PURPOSE
• To gather the baseline data about
the patients health status.
• To identify and confirm the nursing
diagnosis.
• For the purposes of making clinical
decisions about a patient changing
health status.
• To evaluate the outcomes of care.

15. METHODS OF PE
1. INSPECTION: In inspection the nurse
watch non-verbal expressions of
emotional and mental status, physical
movement, patient grooming, hygiene,
skin color etc.
2. PALPATION: It involves the sense of
touch by palpating skin for
assessment examine the size,
consistency, texture, location, and
tenderness of an organ or body part.
Different parts of hand can be used for

16. TYPES OF PALPATION
• Light palpation (superficial): with light
palpation extend the dominant hands fingers
parallel to the skin surface & presses gently
while moving in a circle. The skin is slightly
depressed to determine the details of mass.
• Deep /Bimanual Palpation: Deep palpation is
done with 2 hands/one hand . Extend the
dominant hand like light palpation, place the
finger pads of the non dominant hand on the
dorsal surface of the distal inter-phalangeal
joint of the middle 3 fingers of the dominant
hand . Top hand applies pressure while lower
hand remains relaxed to perceive tactile
sensation. It is done with extreme caution

18. 3. PERCUSSION: Percussion is the act of
striking the body surface to elicit sounds
that can be heard or vibrations that can be
felt. • It is used to guess the size, borders,
and texture of some chest organs and
organs in the abdomen.
There are 2 types of percussion-
a)Immediate or direct percussion refers to
tapping (percussion) done by striking the
fingers on the surface of the chest or
abdomen.
b)Indirect, mediate, or finger percussion is
striking a finger of one hand on a finger
of the other hand as it is placed over an

20. 4. AUSCULTATION: Auscultation is listening to
sound produce by the body. Through auscultation
the nurse note the following characteristics of
sound. Stethoscope Used to evaluate sounds
created by cardiovascular, respiratory, and
gastrointestinal systems Position stethoscope
between index and middle fingers.

21. ARTICLES
1) Gown for the
patient
2) Disposable gloves
3) Sphygmomanomet
er
4) Stethoscope
5) Snellen chart
6) Torch
7) Ophthalmoscope
8) Otoscope
hammer
10)Ruler
11)Inch tape
12)Tongue depressor
13)Tuning fork
14)Vaginal speculum
15)Weighing machine
16)Stadiometer
17)Proctoscope

22. GOWN FOR THE PATIENT
SPHYGMOMANOMETER

23. STADIOMETER
OTOSCOPE

24. SNELLEN CHART
OPHTHALMOSCOPE

25. PERCUSSION HAMMER
INCH TAPE

26. TONGUE
DEPRESSOR
TUNING FORK

27. NASAL SPECULUM
VAGINAL SPECULUM

28. PROCTOSCOPE

29. 1. GENERAL APPEARANCE
Gender and race
Age
Sign of distress
Body built
Posture
Gait
Body movements
Hygiene and grooming
Dress

30. 2. HEIGHT & WEIGHT
A relationship of height and weight
reflects a person’s general health
status. Patient can be identified by
healthy weight, obese and under
weight and children can be
identified for malnutrition and
delay growth and development.

31. 3. NEUROLOGIC ASSESSMENT
Level of consciousness
Level of orientation
4. SKIN
Observe skin for color,
temperature, moisture, texture,
turgor, and evidence of injury or
skin lesions.
Note color of sclera, mucous
membranes, tongue, lips, nail beds,
palms, and soles.

32. SKIN COLOR VARIATIONS
Cyanosis due to heart or lung
disease, cold envt.
Pallor caused by anemia or shock
Vitiligo due to congenital
condition
Yellow-orange(jaundice) due to
liver disease, destruction of
blood cells.
Red (erythema) due to fever,
direct trauma.
Tan-brown (suntan and
pregnancy)

35. SKIN MALIGNANCIES

36. 5. HEAD
Size and shape of skull.
Determine the quantity, quality,
and distribution of hair.
Alopecia
Hair should be smooth, not oily
or dry.
Scalp should be free of dandruff,
lesions, or parasites.
Pediculi

37. 6. FACE & NECK
It includes assessment of head,
eyes, ears, nose, mouth, pharynx,
and neck (lymph nodes, carotid
artery, thyroid gland and trachea).

38.  EYE

39. PRESBYOPIA

40. RETINOPATHY

41. STRABISMUS

42. CATARACT
GLAUCOMA

43. MACULAR DEGENERATION

45.  NOSE
• When inspecting the external nose
observe for size shape symmetry,
presence of deformity and inflammation.
• Note for any polyps and purulent
drainage.
• Examine sinuses involves palpation.
• In case of allergies or infection the
inferior sinuses become inflamed and
swollen.

46.  EAR

47. 9. CHEST

50. 10. ABDOMEN
The abdominal examination consists of four basic
components: inspection, palpation, percussion, and
auscultation.

52. 11. EXTREMITIES

53.  NAILS
Condition of the
nails reflects a
person’s general
health, state of
nutrition,
occupation, and
habits of self
care.

54. 12.VERTEBRAE

55. 12. GENITELIA