History Taking and Physical Examination:

An Overview

Prepared and presented by

Marc Imhotep Cray, M.D.
Learning Objectives:
By the end of this presentation the learner should be able:
 To understand the general principles of the approaches to the patient
 To describe the seven components of the comprehensive adult medical
history
 To explain the essential components of preparing for the physical
examination
 To describe the equipment required for the physical examination
 To list the general sequence of the physical examination
 To describe the four cardinal techniques used in preforming the physical
examination

Marc Imhotep Cray, M.D. 2

Approaches to Patient: General principles
General Objectives
When physician (or student) approaches a patient (pt.) there are four initial
objectives:
1. Obtain a professional rapport with pt. and gain his confidence
2. Obtain all relevant information which allows assessment of illness, and
provisional diagnoses
3. Obtain general information regarding pt., his background, social situation
and problems
 In particular it’s necessary to find out how illness has affected him, his family, friends,
colleagues and his life
4. Understand pt.’s own ideas about his problems, his major concerns & what
he expects from hospital admission, outpatient or general practice visit
Marc Imhotep Cray, M.D. 3
Approaches to Patient: General principles(2)
Specific objectives
In taking a history (Hx) or making an examination (PE) there
are two complementary aims:
1. Obtain all possible information about a pt. and his
illness (a database)
2. Solve problem as to diagnoses

Marc Imhotep Cray, M.D. 4

Approaches to Patient: GPs (2)
Analytical approach
 For each symptom (Sx) or sign (Sn) one needs to think of a
differential diagnosis (DDx), and  of other relevant information
(by history, examination or investigation) which one will need to
support or refute these possible diagnoses

Self-reliance
 The student must take his own history, make his own
examination and write his own clinical records

Marc Imhotep Cray, M.D. 5

Approaches to Patient: GPs (3)
What is important when you start?
 At basis of all medicine is clinical competence
 No amount of knowledge will make up for poor technique
 It is essential to learn and practice the basic ABC of clinical medicine,
introduced in this sequence:
 how to relate to patients (communication skills)
 how to take a good history efficiently, knowing which question to
ask next and avoiding leading questions
 how to examine patients in a logical manner, in a set routine which
will mean you will not miss an unexpected sign
 apply yourself
 initially learn by rote which skills are appropriate for each situation
Marc Imhotep Cray, M.D. 6
Differences Between Subjective
& Objective Data
Subjective Data Objective Data
 What the patient tells you  What you detect during examination
 The history, from Chief Complaint  All physical examination findings
through Review of Systems  Also, laboratory test and other diagnostic/
investigative techniques

Example: Mrs. G is a 54-year-old Example: Mrs. G is an older, over-weight white

hairdresser who reports pressure female, who is pleasant and cooperative.
over her left chest "like an elephant Height 5’4 weight 150 lbs., BMI 26, BP 160/ 80,
sitting there," which goes into her HR 96 and regular, respiratory rate 24,
left neck and arm. temperature 97.5 F

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 History Taking
Here we describe the seven components of the
Comprehensive Adult Health History:
1. Identifying Data and Source of the History
2. Chief Complaint(s)
3. Present Illness
4. Past History
5. Family History
6. Personal and Social History
7. Review of Systems

Marc Imhotep Cray, M.D. 8

 1. Identifying Data
 Identifying data—such as age, gender, occupation, marital status

 Source of history—usually patient, but can be a family member

or friend, letter of referral or medical records

 If appropriate, establish source of referral, because a written

report may be needed

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3. Chief Complaint (CC) /Reliability
Varies according to the patient's memory, trust and mood

The one or more symptoms or concerns causing the patient

to seek care

Marc Imhotep Cray, M.D. 10

 3. Present Illness (HPI)
 Amplifies Chief Complaint; describes how each symptom
developed

 Includes patient's thoughts and feelings about the illness

 Pulls in relevant portions of the Review of Systems, called

“pertinent positives and negatives”

 May include medications, allergies, habits of smoking and

alcohol, which are frequently pertinent to the present illness
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 4. Past History (PMH)
 Lists childhood illnesses

 Lists adult illnesses with dates for at least four categories:

 Medical
 Surgical
 Obstetric/gynecologic
 Psychiatric

 Includes health maintenance practices such as immunizations,

screening tests, lifestyle issues, and home safety
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 Family History (FH)
 Outlines or diagrams age and health, or age and cause of
death, of siblings, parents, and grandparents

 Documents presence or absence of specific illnesses in family,

such as hypertension, diabetes, coronary artery disease , etc.

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Personal and Social History (PH & SH)
Describes:
 educational level
 family of origin
 current household
 personal interests and
 lifestyle/habits

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Review of Systems (ROS)
 Documents presence or absence of common symptoms related to
each major body system
 Review of systems (or symptoms) is a list of questions, arranged by organ system,
designed to uncover dysfunction and disease can be applied in several ways:
1. As a screening tool asked of every patient that you encounters
2. Asked only of patients who fall into particular risk categories (e.g. reserving questions designed to
uncover occult disease of prostate to men over 50)
3. To better define likely causes of a presenting symptom, as described in HPI section (e.g. patients
w/a chief concern of "chest pain" would be asked detailed cardiac and pulmonary ROS)

 What's the best way to use ROS? Makes sense if following hold true:
o Questions asked reflect an array of common and important clinical conditions
o These disorders would go unrecognized if patient was not specifically prompted
o Identification of these conditions then has a positive impact on morbidity/mortality
Marc Imhotep Cray, M.D. 15
The Comprehensive Adult Physical
Examination
Beginning the Examination: Setting the Stage
 Before you begin the physical examination, take time to prepare for
tasks ahead

 Think through your approach to patient, your professional

demeanor, and how to make patient feel comfortable and relaxed

 Review measures that promote patient’s physical comfort and make

any adjustments needed in lighting and surrounding environment
See Physical Diagnosis: Approach to the Patient
(66 CORE ESSENTIALS in sequence, as to not have patient reposition unwarranted.)
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Equipment for Physical Examination
 An ophthalmoscope and an otoscope
• If otoscope is to be used to examine children, it should allow for pneumatic otoscopy
 A flashlight or penlight
 Tongue depressors
 A ruler and flexible tape measure, preferably marked in centimeters
 A thermometer
 A watch with a second hand
 A sphygmomanometer
 A stethoscope with following characteristics:
• Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of proper size, align ear pieces with
angle of your ear canals, and adjust spring of connecting metal band to a comfortable tightness
• Thick-walled tubing as short as feasible to maximize the transmission of sound: approximately 30 cm
(12 inches), if possible, and no longer than 38 cm (15 inches)
• A bell and a diaphragm with a good changeover mechanism
Marc Imhotep Cray, M.D. 17
Equipment for Physical Examination
cont.
 Gloves and lubricant for oral, vaginal, and rectal examinations
 Vaginal specula and equipment for cytological and bacteriological study
 A reflex hammer
 Tuning forks, ideally one of 128 Hz and one of 512 Hz
 Q-tips, safety pins, for testing two-point discrimination
 Cotton for testing the sense of light touch
 Two test tubes (optional) for testing temperature sensation
 Paper and pen or pencil

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PE: Summary of Suggested Sequence
 General survey  CV, for murmur of aortic insufficiency
 Vital signs Optional: thorax and lungs-anterior
 Skin: upper torso, anterior and posterior  Breasts and axillae
 Head and neck, including thyroid and  Abdomen
lymph nodes  Peripheral vascular; Optional: skin-lower
Optional: nervous system (mental status, cranial torso and extremities
nerves, upper extremity motor strength, bulk, tone
 Nervous system: lower extremity motor
and cerebellar function)
strength, bulk, tone, sensation; reflexes;
 Thorax and lungs
Babinskis
 Breasts
 Musculoskeletal, as indicated
 Musculoskeletal as indicated: upper
Optional: skin, anterior and posterior
extremities Optional: nervous system, including gait
 Cardiovascular, including JVP, carotid Optional: musculoskeletal, comprehensive
upstrokes and bruits, PMI, etc.  Women: pelvic and rectal examination
 Marc
CV,Imhotep
for S3Cray,and
M.D. murmur of mitral stenosis  Men: prostate and rectal examination 19
Cardinal Techniques of
the Physical Examination
 Inspection
 Palpation
 Percussion
 Auscultation

Marc Imhotep Cray, M.D. 20

 Inspection
Close observation of details of patient's:
 appearance
 behavior, and movement such as facial expression
 mood
 body habitus and conditioning
 skin conditions such as petechiae or ecchymoses
 eye movements
 pharyngeal color
 symmetry of thorax
 height of jugular venous pulsations
 abdominal contour
 lower extremity edema and
 gait
Marc Imhotep Cray, M.D. 21
 Palpation
Tactile pressure from the palmar fingers or finger pads to assess:
 areas of skin elevation or depression
 warmth, or tenderness
 lymph nodes
 pulses
 contours and sizes of organs and masses and
 crepitus in the joints

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 Percussion
 Use of striking or plexor finger, usually third digit, to deliver
a rapid tap or blow against distal pleximeter finger, usually
distal third finger of left hand laid against surface of
chest or abdomen, to evoke a sound wave such as
resonance or dullness from underlying tissue or organs
• This sound wave also generates a tactile vibration against
pleximeter finger

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 Auscultation
Use diaphragm and bell of stethoscope to detect characteristics of:
 heart
 lung and
 bowel sounds
including: location, timing, duration, pitch, and intensity
• For heart this involves sounds from closing of four valves
and flow into the ventricles as well as murmurs

 Auscultation also permits detection of bruits or turbulence over

arterial vessels
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Comprehensive History and
Physical Examination Capsule
History of Present Illness (HPI) Vital Signs (VS)
The Rest of the history: Eye Exam
Past Medical History(PMH) HEENT
Head and Neck Exam
Past Surgical History (PSH) Lung Exam
Medications (Meds.) Cardiovascular Exam
Allergies/Reactions Exam of the Abdomen
Social and Personal History: Breast Examination
(Smoking, Alcohol, Drugs of abuse) Male Genital and Rectal Exam
Obstetric (where appropriate) Exam of Upper Extremities
Sexual Activity Exam of Lower Extremities
Family History (FH) Musculo-Skeletal Examination
Work/Hobbies/Other Neurological Examination
Military Service
Adult Review of Systems (ROS) See Physical Exam Checklists

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The History and Physical Examination:
Comprehensive or Focused?
Comprehensive Assessment Focused Assessment
 Is appropriate for new patients in office or  Is appropriate for established
hospital patients, especially during routine or
 Provides fundamental and personalized urgent care visits
knowledge about patient  Addresses focused concerns or
 Strengthens the clinician-patient relationship symptoms
 Helps identify or rule out physical causes related  Assesses symptoms restricted to
to patient concerns a specific body system
 Provides baselines for future assessments  Applies examination methods
 Creates platform for health promotion through relevant to assessing concern or
education and counseling problem as precisely and carefully as
 Develops proficiency in the essential skills of possible
physical examination
Marc Imhotep Cray, M.D. 26
Summary of the Diagnostic process

Step 1: Take a History: Elicit symptoms and a timeline; begin a

problem list.
Step 2: Develop Hypotheses: Generate a mental list of anatomic
sites of disease, pathophysiologic processes, and diseases that might
produce the symptoms.
Step 3: Perform a Physical Examination: Look for signs of the
physiologic processes and diseases suggested by the history, and
identify new findings for the problem list.
Step 4: Make a Problem List: List ALL the problems found during the
history and physical examination that require an explanation.

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Summary of Diagnostic process(2)
Step 5: Generate a Differential Diagnosis: List the most probable
diagnostic hypotheses with an estimate of their pretest probabilities.
Step 6: Test the Hypotheses: Select laboratory tests, imaging studies,
and other procedures with appropriate likelihood ratios to evaluate
your hypotheses.
Step 7: Modify Your Differential Diagnosis: Use the test results to
evaluate your hypotheses, eliminating some, adding others, and
adjusting the probabilities.
Step 8: Repeat Steps 1 to 7: Reiterate your process until you have
reached a diagnosis or decided that a definite diagnosis is neither
likely nor necessary.
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Summary of Diagnostic process(3)

Step 9: Make the Diagnosis or Diagnoses: When the tests of your

hypotheses are of sufficient certainty that they meet your stopping
rule, you have reached a diagnosis.
If uncertain, consider a provisional diagnosis or watchful waiting.

Decide whether more investigation (return to Step l), consultation,

treatment, or watchful observation is the best course based upon the
severity of illness, the prognosis, and comorbidities.

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 THE END

See next slide for links to tools

and resources for further study. 30
Sources and Further Study:
Cloud Folders
Introduction to Clinical Medicine I (ICM-1)
Introduction to Clinical Medicine II (ICM-2)

Bate’s Guide to the Physical Examination and History Taking, Lynn Bickley (with Video)

DeGowin’s Diagnostic Examination, 9th Ed. Richard DeGowin,et al.

Textbook of Physical Diagnosis: History and Examination, Mark Schwartz. (with Video)

A Practical Guide to Clinical Medicine, Charlie Goldberg and Jan Thompson.

(A PDF version of the website compiled by this presenter.)

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