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PHYSICAL EXAMINATION & HISTORYTAKING

sets the direction of clinical thinking

governs your next steps with the patient

embody time-honored skills

history: sensitive & nuanced

PE: thorough & accurate

empathic listening (an essentialelement)NOTE: Patients are unique individuals.

A. HEALTH HISTORYComprehensive Adult Health History:

[Dont forget: DATE & TIME]1. Identifying Data & Source of History

Identifying Data: age, gender,occupation, marital status

Source of History: patient, familymember or friend, letter of referral, ormedical record

Source of Referral because a writtenreport may be needed (if appropriate)

Reliability: Reflects quality of infoprovided by the patient. Usually madeat the end of the interview. Varies w/patients memory, trust, and mood.Ex: The patient is vague in describing

the symptoms, and details areconfusing.

2. Chief complaint(s)

Concerns causing the patient to seek

care Make every attempt to quote patients

own words.

Ex: My stomach hurts and I feelawful.

I have come for my regular check-up.I have been admitted for athorough evaluation of my heart.

3. Present Illness

Amplifies the CC

Complete, Clear, & Chronologic Includes patients thoughts & feelings

Pulls in relevant portions of ROScalled pertinent positives &negatives

Should reveal patients responses toSx & what effects the illness had onthe patients life

Each symptom merits its ownparagraph & full description

O Onset (4) [timing]L Location (1)D Duration (4) [timing]C Characteristics: quality &quantity (2) (3)A Aggravating/Alleviating (6)R Related S/Sx (7)T Treatment* (5) Setting in w/c the s/sx occurred

* Relate pertinent positives &pertinent negatives from ROS w/

CC(s). This designatespresence/absence of sx relevant tothe Differential Dx(most likely Dx).

OOnset SSiteP Provoking/Palliative T

TimingQ QualityR RadiationMedications used: name, dose, route, &

frequency (include home remedies,OTC, vitamins, mineral or herbalsupplements, oral contraceptives)

Allergies: include specific rxns

Tobacco use: type & pack-years; ifsomeone has quit, note how longCompute: 5 sticks/day for 10yrs = 5/20x10 = 2.5

1.5 packs/day for 12yrs = 18-pack-yr hx

Alcohol & Drug use:- avoid restricting the personal &

social hx to these topics if you placethem there

- often contributes to symptoms

Alcohol:

- Q: What do you like to drink?Tell me about your use ofalcohol.Have you ever had a drinkingproblem?When was your last drink?

CAGE Questionnaire:C Cutting down

A Annoyed by criticismsG GuiltyE Eye opener* 2 or more affirmative answers

suggest alcohol misuse: sensitivityof 43-94%, specificity of 70-96%.

*if you detect misuse, ask:

Blackouts (loss of memory)

Seizures

Accidents / Injuries

Job problems

Conflicts in relationships Legal problems

Drinking while driving / operatingmachinery

Illicit Drugs:- Q: Have you ever used any drugs

other than those required for medicalreasons?

- Last use, how often, amount

- Modes of consumption (inj, pills,inhaled, etc.)

- Adapt CAGE questions by adding or

drugs w/ each question- Once you identify substance abuse,

ask:

Able to control

Any bad reactions

Accidents, injuries, arrests

Job / Family problems

Tried to quit4. Past History

Childhood illnesses:-Measles, rubella, mumps, whooping

cough, chickenpox, rheumatic fever,scarlet fever, polio

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-Include chronic childhood illnesses

Adult illnesses :

-Medical:*DM, HTN, hepa, asthma, HIV*Hospitalizations, # & gender of

sexual partners, risky sexualpractices

-Surgical:

*Date, type, indications-Obstetric/Gynecologic :

*Obstetric hx, menstrual hx,contraception, sexual fxn

-Psychiatric:*Dx, time frame, hospitalizations,tx

Health maintenance aspects:-Immunizations

*Tetanus, pertussis, diphtheria,polio, measles, rubella, mumps,influenza, varicella, hepa B, H.Inflenzae type B, pneumococci

-Screening tests*TB, Pap smears, mammograms,

occult blood, cholesterol*Results*If patient doesnt know, written

permission may be neededA AllergiesM MedicationsP Past hospitalizationsL Last meal

E Events leading to5. Family History

Outlines / diagrams age, health, causeof death of siblings, parents,grandparents, children, grandchildren

Review the ff. conditions:-HTN, CAD, elev. Cholesterol, stroke-DM, thyroid/renal disease, arthritis-TB, asthma / lung diseases-Headache, seizure d/o-Mental illness, suicide, substance

abuse

-Allergies-Breast, ovarian, colon or prostate CA

-Genetically transmitted diseases6. Personal & Social History

Educational level, Occupation

Home situation

Support & coping, Sources of stress

Important life experiences

Personal interests

Leisure activities

Religious affiliation & Spiritual beliefs ADLs

Lifestyle (promote health/createsrisk): exercise & diet, safety mxrs, alt.HC practices

7. Review of Systems

Documents presence/absence ofcommon symptoms r/t each majorbody system

Head-to-toe

Prepare patient: The next part may

feel like a hundred questions, but theyare important.

May uncover problems the patientmay have overlooked

Organize into written format after hx& PE

Start w/ fairly general question

General: usual wt, change, clothes fit,weakness, fatigue, fever

Skin: rashes, lumps, sores, itch,dryness, change in color; hair,nail, mole changes

HEENT: Head: injury, dizziness,headache

Eyes: vision, glasses/lenses, lastexam, problems

Ears: hearing, aids, problemsNose & sinuses: problems (colds,

etc.)Throat (mouth & pharynx):

teeth, gums, dentures, lastexam, problems

Neck: swollen glands, lumps, pain,stiffness

Breasts: lumps, pain, discharge, self-examRespi: problems (cough, DOB, etc.), lastxrayCardio: problems (BP, pain,palpitations), ECGGI: problems (swallowing, appetite,

nausea, bowel habits, hemorrhoids,

jaundice, etc.)Peripheral vascular: leg cramps,claudication, varicosities, swellingextremities, color, etc.

Urinary: frequency, any discomforts,force, etc.

Genital: M: discharges, sores, mass,sexual habits, birth control

F: menarche, periods (regular,frequency, duration), amountof blood, bleeding bet. periods,LMP, dysmenorrheal; problems

(discharges, sores, lumps);menopause; pregnancies, birthcontrol

Musculoskeletal : problems (joint pain,stiffness, backache, trauma, etc.)

Psychiatric: nervousness, mood, suicideNeurologic: mood, attention, speech,

memory, fainting, seizures,weakness/paralysis, tingling pins &needles, involuntary movements

Hematologic: anemia, easy bruising,past BT, rxn

Endocrine: heat/cold intolerance;excess sweat, thirst, hunger;polyuria; change in glove/shoe size

*While talking with the patient, learn toelicit and organize these elements.

*Information will NOT spring forth in thisorder.

*In many situations, a more flexiblefocused, orproblem-oriented, interviewmay be appropriate.

*Usually, the interview will follow thepatients leads and cues.

*Choose the elements from thecomprehensive health hx that will be

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most helpful for addressing patientconcerns.

Factors:

1. Magnitude & severityof patientsproblems

2. Need for thoroughness3.The clinical setting

(inpatient/outpatient, etc.)

4. Amount oftime availableComprehensive Assessment: (Hx & PE)

For new patients

Provide fundamental &personalizedknowledge about the patient

Strengthens clinician-patient relationship

Helps identify/rule outcauses r/t aegconcerns

Provide baselines

Creates platform for health promotion

Develops proficiency in PE

Focused Assessment: (Hx & PE)

For establishedpatients

Addresses focusedconcerns

Restricted to a specific body system

Assessing asprecisely& carefully aspossible

Routine Clinical Check-up / Periodic PE* The comprehensive PE has been

scrutinized for purposes of screening andprevention of illness.

* Findings have validated the importanceof:

BP measurement

CVP from jugular venous pulse

Listening to d heart for evidence ofvalvular dse

Clinical breast examination

Detection of hepatic and splenicenlargement

Pelvic examination (pap smears)

Subjective data:

What thepatienttells you

The history(CC to ROS)

Objective data:

Whatyou detect

Physical Examination

* Knowledge of these diff. helps you clusteraeg info.* Both are equally important.

B. PHYSICAL EXAMINATION

Setting the Stage/Preparation for PE:(ALECS)1) Reflect on your APPROACH

Be straightforward

Identify yourself as a student

Try to appear calm, organized &competent

Forgetting is common, simply examinethe area out of sequence

If you know that youre going to taketime in auscultation (since u rinexperienced), inform patientbeforehand so as not to alarm him/her

Examine each region & at the sametime sense the whole patient

Note any winces or worried glance

Share info that can calm & reassurepatient

AVOID interpreting your findings

Always AVOID showing negativereactions

2) LIGHTING & ENVIRONMENT

Good lighting

*Tangential lighting casts light acrossbody surface that throws contours,depressions, elevations,moving/stationary, into sharper relief.

*Perpendicularto a surface shadowsare reduced.

Quiet environment

Awkward positions impair quality of PE

Adjust the bed/ask patient to movetoward you if it makes it easier

Be courteous to ask someone for help

3) EQUIPMENT1. Ophthalmoscope

2. Otoscope (children: allowpneumatic otoscopy)

3. Flashlight/ Penlight4. Tongue depressors

5. Ruler& flexible tape measure(cm preferably)6. Thermometer

7. Watch w/ second hand

8. Sphygmomanometer 9. Stethoscope w/ ffcharacteristics:

Ear tips should fit snugly & painlessly

Thick-walled tubing as short asfeasible to maximize transmission ofsound: 30cm (12in), no longer than38cm (15in)

Good changeover mechanismbetween bell & diaphragm

10. Reflex hammer

11. Tuning forks (128 & 512Hz)12. Q-tips, safety pins, otherdisposable objects for two-pointdiscrimination

13. Cotton for testing the sense oflight touch

14. 2 test tubes (optional) fortesting temperature sensation

15. Gloves & lubricantfor oral,vaginal or rectal exam

16. Vaginal specula & equipmentfor cytological/bacteriological study

17. Paper & Pen/Pencil4) Make the patient COMFORTABLE

Concern for privacy & patient modesty- Close nearby doors, draw curtains

Goal is to visualize one body area at atime

Briefly describe your plans beforestarting

As you proceed, keep the patientinformed

Gauge how much the patient wants to

know the findings

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Make sure instructions are courteous &clear

Be sensitive, watch patients facialexpressions

Adjust bed, rearrange pillows, addblankets for warmth

When PE is complete, tell patient yourgeneral impressions & what to expect

next If hospitalized patient, rearrange

environment, lower bed & raise bedrailsto avoid falls

Wash hands, clean your equipment, &dispose waste materials after PE

5) Choose the SEQUENCE

The key to a thorough & accurate PE isdeveloping a systematic sequence ofexam

3 goals:

1. Maximize patients comfort.2. Avoid unnecessary changes inposition

3. Enhance clinical efficiency In general, move form head-to-toe

If patient is at bed rest, examine head,neck, & anterior chestwhile supine. Rollpatient to examine lungs, back, & skin.Roll back & finish the rest.

Cardinal Techniques of Examination:

INSPECTION: appearance, behavior, skin,

etc.PALPATION: tactile pressure from palmarfingers to fingerpads.

PERCUSSION: use of striking/plexorfingeragainst the distalpleximeterfingerto evoke sound.

AUSCULTATION: use of diaphragm/bell ofthe stethoscope to detect heart,lung, bowel sounds, & bruits overvessels.

Standard & Universal Precautions (CDC Centers for Disease Control &

Prevention): Standard & MRSA precautions

- All blood, body fluids, secretions,excretions may contain transmissibleinfectious agents EXCEPT sweat,nonintact skin, & mucous mem.

- Applies to all patients in any setting- Hand hygiene; gloves; gowns; mouth,

nose & eye protection; respiratoryhygiene & cough etiquette; patient

isolation; equipment & laundry prec.;safe needle-injection practices.- Change your white coat frequently

Universal precautions- Prevent transmission of HIV, HBV, other

blood-borne pathogens- The ff. fluids are considered potentially

infectious:

All blood & other body fluids containingblood, semen, & vaginal secretions

CSF, synovial, pleural, peritoneal,pericardial, & amniotic fluids

- Gloves, gowns, aprons, masks, & eyewear- Safe injections, prevention of injury from

needlesticks, scalpels, & other sharpinstruments

- Report IMMEDIATELY if injury occurs.

Comprehensive Adult PhysicalExamination:

1. General Survey- health, height, weight, build, sexualdevt- posture, motor activity, gait- hygiene, odor- facial expressions, reactions- manner or speaking- awareness, LOC

2. Vital signs (Sitting position)3. Skin- moisture/dryness- temperature- lesions- [I&P] hair, nails4. HEENT

Head: hair, scalp, skull, face

Eyes: acuity, fields, position &alignment, eyelids, sclera,conjunctiva; cornea, iris, lens(oblique lighting); PERRLA;extraocular movements;ophthalmoscope inspect fundi (dimroom)

Ears: auricles, canals, drums, acuity,

Webertest (lateralization), Rhinnetest (air & bone conduction)Nose & Sinuses: external nose (use light

& nasal speculum), nasal mucosa,septum, turbinates, [P] tendernessof sinuses

Throat: lips, mucosa, gums, teeth,tongue, palate, tonsils, pharynx,cranial nerves

5. Neck - [I&P] cervical lymph nodes, masses,unusual pulsations, deviation of

trachea, sound & effort of breathing,thyroid gland (go behind)6. Back - [I&P] spine & muscles, shoulder ht &symmetry7. Posterior Thorax & Lungs- [I&P] spine & muscles of upper back- [I,P,P] chest, identify diaphragmaticdullness- [A] breath sounds, adventitious sounds,

transmitted voice sounds8. Breasts, Axillae, & Epitrochlear

Nodes- [I] arms relaxed, elevated, thenpressed on hips- axillae, [P] nodes, epitrochlear nodes

- musculoskeletal exam: hands, arms,shoulders, neck, & Temporomandibularjoints

- [P] breasts9. Anterior Thorax & Lungs- [I,P,P] chest- [A] breath sounds, transmitted voicesounds

10. Cardiovascular System

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- jugular venous pulsations, mxr jugularv. pxr- [I&P] carotid pulsations, [A] carotidbruits- [I&P] precordium, apical impulse- [A] using diaphragm: each auscultatoryarea

using bell: apex & lower sternal

border listen for 1st & 2nd heart sounds & for

physiologic splitting of 2nd heartsound

listen for abnormal heart sounds

11.Abdomen [I,A,P,P]- Palpate lightly then deeply- [Pe,Pa] liver & spleen, kidneys- Palpate aorta & its pulsations12. Lower Extremities

Supine

Peripheral Vascular System [I,P]- femoral & popliteal pulses- inguinal lymph nodes- edema, discoloration, ulcers

Musculoskeletal System- deformities / enlarged joints- ROM

Nervous System- muscle bulk, tone, & strength- sensation & reflexes- observe for abnormal movements

Standing (while you sit in a stool)

Peripheral Vascular System- inspect varicose veins

Musculoskeletal System- alignment of spine, ROM- alignment of legs, & feet

Genitalia & Hernias in Men- examine penis & scrotal contents- check for hernias

Nervous System- gait, ability to walk heel-to-toe, ontoes, on heels, hop in place, & shallowknee bends

-Do a Romberg test & check forpronator drift

13.Nervous System (5 segments)

Mental Status:- orientation- mood- thought process & content- abnormal perceptions

- insight & judgment- memory & attention- information & vocabulary- calculating abilities- abstract thinking- constructional ability

Cranial Nerves:- smell- temporal & masseter muscles- corneal reflexes- facial movements- gag reflex

- trapezia & sternomastoid muscles Motor System:

- muscle bulk, tone, strength, gait- cerebellar function: repid alternating

movements (RAMs), point-to-pointmovements e.g. finger-to-nose,heel-to-shin

Sensory System:- pain, temperature, light touch,vibration discrimination

-compare R w/ L sides & proximal w/

distal area Reflexes:

- biceps, triceps, brachioradialis,patellar, Achilles deep tendonreflexes, plantar & Babinski reflexes

14. Additional Examinations

Rectal Examination in Men:- [I] sacrococcygeal & perianal areas- [P] anal canal, rectum, & prostate- If patient cannot stand, examine

genitalia first before rectal exam

Genital & Rectal Exam in Women:

- [I] external genitalia, vagina, & cervix- Obtain Pap smear

- [P] uterus & adnexa bimanually

RADJA,NASHEERA