Adult History Taking and Physical

Examination Example for Clarification

Dr. Nadala Patient: Doc I have diarrhea.
June 10, 2013 Doctor: What do you mean when you say “diarrhea”?
Group 3
 Confrontation- say something that you
HISTORY TAKING noticed about the patient
Steps in Interview  Interpretation
I. Introduce Self  Empathic Responses
- Proper use of names and titles  Asking about feelings
- Critical determinant of reflexive self
concept Contents Of A Complete Client History
II. (skipped by Doc Nadala) I. General Data
III. Beware of the standing between patient and II. Chief Complaint
III. History of Present Illness
light
IV. Past Medical History
- Unwittingly conduct and
V. Family History
interrogation VI. Personal and Social History
- Avoid use of dark glasses VII. Obstetrical and Menstrual History
IV. Personal Appearance of Doctor
- Well kempt, well-groomed
- Respectable garments I. General Data – getting to know the patient
V. Note Taking
- Avoid taking down notes during
interview; have another person list Name Ward
down the notes for you to avoid Age Informant
distractions between doctor-client Sex Reliability of Informant
communication Civil Status (%)
Nationality Historian (name)
Conducting The Interview Religion Med II –
- Thoughtful formulation of questions Occupation Group –
- Avoid leading queries Residence Date History Taken
- Avoid “yes” or “no” questions No. of Date of Admission
- Do not suppress patient’s thoughts Admissions
- Offer multiple choice questions
- Ask one question at a time  These data could serve as predisposing factors
- Use language that is understandable of an illness state
and appropriate to the patient  Source of history
 Patient
Methods of Guiding Patients  Family member
 Facilitation- encourage patient to speak  Friend
more about his/her condition  Letter of Referral
 Reflection- repeat some words that patient  Medical record
says so that he/she will know you  A “source of referral” may also be appropriate
understand since a written report may be necessary.
 Clarification- to check if you are in the same  Reliability varies according to patient’s memory,
page trust to care provider and mood.

1
 II. Chief Complaint 4. Associations with:
a. Other symptoms
 One or more symptoms causing the patient b. Posture
to seek care c. Movement
 verbatim patient’s own words d. Physiologic functions
 Avoid diagnostic words e. Aggravating/alleviating factors

NOT BUT Examples:

 Pain
-Diabetes - Excessive Urination
-location, radiation
-Pneumonia - Cough & Fever -character (sharp, dull, colicky)
-Heart Problem - Chest Pain -severity, duration
-associations (meals, motion, sleep)
Symptom  Fever
- abnormal functioning, appearance or -grade
sensation experienced by the patient -character (intermittent, remittent, continuous,
- Subjective data septic, hectic)
-associations (head ache, sweating)
Sign  Cough
- discovered by the physician upon -productive (w/sputum)/dry
-character of expectoration
examination
-severity, frequency
- abnormality indicative of disease -associations (fever, etc.)
- Objective data  Vomiting
-frequency
III. History of Present Illness -timing with meals
-amount
 Amplifies chief complaint -character of vomitus
 Describe how each symptom developed -delivery
 Includes patients thoughts and feelings about -associations/provoking factors
the illness  Weight loss
 Could include relevant portions of review of -duration
systems -degree
-associations (anorexia, GI complaints)
 May include medications, allergies, habits of
smoking and alcohol if related to present
5. Effects of Disease
illness a. Weight loss
b. Malaise
-start with symptoms relevant to present c. Anorexia
admission 6. Prior treatment (ailment might be secondary)
-allow patient to tell his own story a. Self medication
b. MD consultation
For each symptom, elicit: i. Tests done
1. Time of occurrence (Prior to Admission) ii. Diagnosis
2. Onset iii. Management
a. Sudden iv. Complaint
b. Gradual c. Hospitalizations
c. Progressive i. Date
3. Character of symptoms ii. Dx, Mx
iii. Course in the ward

2
 iv. Duration of stay  Living arrangements
v. Condition @ discharge  Physical and social aspects of home and
7. Relief of symptoms environment
8. Recurrences
 Personal interests
9. Pertinent positives & negatives
a. Do not repeat what has been written  Lifestyle
b. Not mentioned by the patient
VII. Obstetrical and Menstrual History
IV. Past Medical History  menarche
o Age of onset
 Childhood diseases o Duration
 Adult illnesses categorized as medical, surgical, o Amount (no. of napkins)
obstetric/ gynecologic or psychiatric With dates o Associated symptoms
 Immunization status  subsequent menses
 Note for screening tests undergone by patient o Regularity
 Maintenance medications o Duration
 History of trauma/accidents o Amount
 History of hospitalizations, operations, illnesses  pregnancies
 History of allergies & adverse drug reaction o G_P_(T-P-A-L)
G – no. of pregnancies
P – No. of live births
V. Family History
(term – preterm – abortions – living)
 Peripartum events
 heredo-familial diseases
Delivery, place, attending personel,
 member of the family
complications
- Age and state of health
 Menopause
- Age and cause of death
Age of onset
*If sick: age of onset of illness and treatment
Associated symptoms
 marital history
o Duration of marriage
o Occupation of partner PHYSICAL EXAMINATION
o Health of spouse – sick/dead Do’s
 no. of children  Pay attention to physician/patient’s comfort
o Ages  Avoid unnecessary exposure and
o Health of children embarrassment
 Avoid expressions of disgust, alarm and
V. Personal, Social &Environmental History distaste
 Keep the patient informed as to what you
 Education, military service and religious intend to do or are doing
activity  Avoid distasteful of unhygienic sequence in
 Occupation doing PE
o Present & past  Avoid reassuring the patient prematurely
o Income, social standing
o Occupational hazards Preparing for the Physical Examination- Bates
o Places of travel, residence
 Alcohol intake ● Reflect on your approach to the patient.
o Kind, amount, frequency, duration ● Adjust the lighting and the environment.
 Drugs ● Make the patient comfortable.
 Sexual preferences ● Determine the scope of the examination.

3
● Choose the sequence of the examination. PE Maneuvers (Note: this is in order!)
● Observe the correct examining position (the Inspection
patient’sright side) and handedness. Palpation
Percussion
PE Overview Auscultation
General Survey - The General Survey begins with *the sequence of PE in the abdomen is usually
the first moments of the patient encounter. How do different from the conventional sequence :
you perceive the patient’s apparent state of health, Inspection, Auscultation, Percussion, Palpation
demeanor and facial affect or expression, grooming,
posture, and gait? Height and weight, usually
recorded before the patient enters the examining A. Inspection
room, add important detail to the General Survey.  General
 Local (certain anatomic region)
Bates: Continue this survey throughout the patient
visit. Observe general state of health, height, build, B. Palpation
and sexual development. Note posture, motor  Act of feeling by sense of touch
activity, and gait; dress, grooming, and personal  Structure examined by palpation
hygiene; and any odors of the body or breath. All external structure
Watch facial expressions and note manner, affect, Accessible through body orifices
and reactions to persons and things in the
environment. Listen to the patient’s manner of Qualities elicited by palpation
speaking and note the state of awareness or level of  texture (skin and hair)
consciousness.  temp.
 Development  masses
 Nourishment  moisture
 General Appearance  precordial thrust
 Mental Style (Alertness, affect, intellect)  crepitus (air in subcutaneous)
 Motor (Ambulant, bed-ridden, posture,  tenderness
abnormal movements)  thrills (murmurs or repulses from the heart)
 fremitus (tactile vibration on the chest upon
Vital Signs talking)- polytactile fremitus
 Blood Pressure
 Heart Rate Palpation
 Pulse Rate  Tactile sense = Tips of fingers
 Respiratory Rate  Temp. sense = Dorsum of hands and fingers
 Temperature  Vibratory sense = Palms
 Height- if not ambulant don’t use tape  Position and Consistency = Grasping fingers
measure
 Weight – rapid change is a good indicator of
changes in body fluids Maneuvers
*usually only TPRBP (temperature, pulse rate,  Light
respiratory rate, BP) are being taken in the real  Deep
setting, but there are journal updates at present  Bimanual
want to include PAIN as the fifth vital sign  Ballotement- for mass inside the fluid,
bouncing feeling after palpation

4
 C. Percussion the connecting metal band to a comfortable
Percussion Methods tightness.
 Bimanual (mediate or indirect)  Thick-walled tubing as short as feasible to
 Immediate or Direct maximize the transmission of sound:
 Sonorous – to ascertain the density of approximately 30 cm (12 inches), if possible, and
underlying structures no longer than 38 cm (15inches)
 A bell and a diaphragm with a good changeover
Notes of Percussion mechanism
 Tympany – abdomen ● Gloves and lubricant for oral, vaginal, and rectal
 Resonance – lungs examinations
 Dullness – solid organs (muscle tissues) ● Vaginal specula and equipment for cytological and
 Flatness – Bone (sternum) perhaps bacteriological study
 Hyperresonance – exaggerated resonance in ● A reflex hammer
the lungs (ex. Emphysema, COPD) ● Tuning forks, ideally one of 128 Hz and one of 512
Hz
Definitive Percussion – to map out the area of ● Q-tips, safety pins, or other disposable objects for
greater density to ascertain the size of the testing two-point discrimination
underlying structure or the extent of its border {ex. ● Cotton for testing the sense of light touch
Dull=Liver, Tympany=intestine} ● Two test tubes (optional) for testing temperature
sensation
D. Auscultation - hearing through stethoscope ● Paper and pen or pencil

Smelling as a PE tool Cardinal Techniques of Examination

 Breath
● Inspection- Close observation of the details of the
 Sputum- eg. Sweet- Pseudomonas Infection
patient’s appearance,behavior, and movement such
 Vomitus
as facial expression, mood, body habitus and
 Feces
conditioning, skin conditions such as petechiae or
 Urine
ecchymoses, eye movements, pharyngeal color,
Additional Notes: Bates
symmetry of thorax, height of jugular venous
EQUIPMENT FOR THE PHYSICAL EXAMINATION
pulsations, abdominal contour,
 An ophthalmoscope and an otoscope. If the lower extremity edema, and gait.
otoscope is to be used to examine children, it
should allow for pneumatic otoscopy. ● Palpation- Tactile pressure from the palmar
● A flashlight or penlight fingers or fingerpads to assess areas of skin
● Tongue depressors elevation, depression, warmth, or tenderness;
● A ruler and flexible tape measure, preferably lymph nodes; pulses; contours and sizes of organs
marked in centimeters and masses; and crepitus in the joints.
● Often a thermometer
● A watch with a second hand ● Percussion- Use of the striking or plexor finger,
● A sphygmomanometer usually the third, to deliver a rapid tap or blow
● A stethoscope with the following characteristics: against the distal pleximeter finger, usually the distal
 Ear tips that fit snugly and painlessly. To get this third finger of the left hand laid against the surface
fit, choose ear tips of of the chest or abdomen, to evoke a sound wave
 the proper size, align the ear pieces with the such as resonance or dullness from the underlying
angle of your ear canals,and adjust the spring of

5
tissue or organs. This sound wave also generates a
tactile vibration against the pleximeter finger.

● Auscultation- Use of the diaphragm and bell of

the stethoscope to detect the characteristics of
heart, lung, and bowel sounds, including location,
timing, duration, pitch, and intensity. For the heart
this involves sounds from closing of the four valves
and flow into the ventricles as well as murmurs.
Auscultation also permits detection of bruits or
turbulence over arterial vessels.

References: Bates Pocket Guide to Physical

Examination and History Taking p.8,11, Lecture