Physical Diagnosis

Nishalini Ravindran

Book: Bate’s Guide to Physical

Examination and History Taking
Nishalini Ravindran

Week 1 (Chapter 1)
(PE Physical Examination)
1. Comprehensive/Focussed Assessment
2. Comprehensive adult history
3. Components of Adult history
4. Review of systems
5. Comprehensive adult PE
6. Equipment for physical exam
7. Cardinal Techniques  Inspection, Palpation, Percussion, Auscultation

Comprehensive or Focussed Assessment?

Comprehensive
st
- 1 time you see patient
- All elements of health history
and complete physical
examination
- Fundamental & personalised
knowledge about patient
- Stronger Dr-patient relationship
- Helps identify/rule out physical
causes of patient concerns
- Baseline for future assessment
- Health promotion via
education/counselling
- Develops proficiency in physical
examination skill
Focussed
- Problem oriented (mostly
appropriate)
- Routine care, patients you know
or Urgent Care
- Restricted to specific body
system
- Examination relevant to
assessing concerned area
- Symptoms, age, health history

Factors to consider: Severity, need for thoroughness, inpatient/outpatient,

primary/subspecialty care, time available

Validated examination techniques: BP, assessment of central venous pressure from the
jugular venous pulse, listening to the heart for evidence of valvular disease, detection of
hepatic and splenic enlargement, and the pelvic examination with Papanicolaou (Pap)
smears.

Subjective or Objective Data?

Subjective Objective
- What patient tells you - What you detect during
- Symptoms & History from chief examination, lab info., test data
complaint via Review of Systems - PE findings/signs
Nishalini Ravindran

Comprehensive Adult Health History

Components of Comprehensive Adult Example

Health History

Identifying data Age, gender, occupation, marital status

Source of history (reliability) Usually Patient, can be family

member/referral letter/
consultant/records (Reliability varies
based on patients trust, memory and
mood)
Chief Complaint(s) Symptoms/concerns causing patient to
seek care
Present Illness Amplifies chief complaint, describes
development of each symptom,
includes patients’ thoughts and feeling
about illness
Medication, allergies, tobacco use,
alcohol
Pertinent + and – of review of systems
Past History Childhood illnesses
Adult illnesses with dates for events in
medical/surgical/obstetric and
gynaecologic/ Psychiatric
Family History Age/cause of death of
siblings/grandparents/parents
Presence/Absence of specific illness in
family such as hypertension/diabetes
Personal & Social History Educational level/family of
origin/personal interests/hobbies
Review of Systems Presence of any common symptoms
related to each major body system

 Date & Time of History

 Reliability of patient (vague in description or confusing details)
 Chief complaint (quote patient as much as possible)
 Present Illness-
- Complete, clear, chronologic description of problems prompting patients visit
- Onset of problem
- Setting in which it developed
- Manifestation and treatment so far

 Symptom Characterisation
Nishalini Ravindran

(1) location (2) quality; (3) quantity or severity; (4) timing, including onset, duration, and
frequency; (5) the setting in which it occurs; (6) factors that have aggravated or relieved the
symptom; and (7) associated manifestations

 Risk Factors and current medications

- Medications note name, dose, route and frequency

Review of Systems

 Begin with general question about system e.g. How are your lungs and breathing?
 Questions on review of systems may uncover problems that patient has overlooked
Remember that major health events discovered during the Review of Systems should be
moved to the Present Illness or Past History in your write-up.

Review of Systems Components

General Usual weight, recent weight change,

clothing that fits more tightly or loosely
than before; weakness, fatigue, or fever.

Skin Rashes, lumps, sores, itching, dryness,

changes in colour; changes in hair or nails;
changes in size or colour of moles.

Head Headache, head injury, dizziness, light-

headedness.

Eyes Vision, glasses or contact lenses, last

examination, pain, redness,
excessive tearing, double or blurred vision,
spots, specks, flashing lights,
glaucoma, cataracts.

Nose and Sinuses Frequent colds, nasal stuffiness, discharge,

or itching, hay fever, nosebleeds, sinus
trouble.

Throat/Mouth and Pharynx Condition of teeth and gums, bleeding

gums, dentures, if any, and how they fit,
last dental examination, sore tongue, dry
mouth, frequent sore throats, hoarseness.

Neck Swollen glands,” goitre, lumps, pain, or

stiffness in the neck.

Breasts Lumps, pain, or discomfort, nipple

discharge, self-examination practices.
Nishalini Ravindran

Respiratory Cough, sputum (colour, quantity; presence

of blood or haemoptysis),
shortness of breath (dyspnoea), wheezing,
pain with a deep breath (pleuritic pain), last
chest x-ray. You may wish to include
asthma, bronchitis, emphy- sema,
pneumonia, and tuberculosis.

Cardiovascular Heart trouble”; high blood pressure;

rheumatic fever; heart murmurs; chest pain
or discomfort; palpitations; shortness of
breath; need to use pillows at night to ease
breathing (orthopnoea); need to sit up at
night to ease breathing (paroxysmal
nocturnal dyspnoea); swelling in the hands,
ankles, or feet (edema); results of past
electrocardiograms or other cardiovascular
tests.

Gastrointestinal Trouble swallowing, heartburn, appetite,

nausea. Bowel movements, stool colour
and size, change in bowel habits, pain with
defecation, rectal bleeding or black or tarry
stools, haemorrhoids, constipation,
diarrhoea. Abdominal pain, food
intolerance, excessive belching or passing
of gas. Jaundice, liver, or gallbladder
trouble; hepatitis.

Peripheral Vascular Intermittent leg pain with exertion

(claudication); leg cramps; varicose veins;
past clots in the veins; swelling in calves,
legs, or feet; colour change in fingertips or
toes during cold weather; swelling with
redness or tenderness.

Urinary Frequency of urination, polyuria, nocturia,

urgency, burning or pain during urination,
blood in the urine (haematuria), urinary
infections, kidney or flank pain, kidney
stones, ureteral colic, suprapubic pain,
incontinence; in males, reduced calibre or
force of the urinary stream, hesitancy,
dribbling.
Nishalini Ravindran

Genital Male: Hernias, discharge from or sores on

the penis, testicular pain or masses, scrotal
pain or swelling, history of sexually
transmitted infections and their
treatments. Sexual habits, interest,
function, satisfaction, birth control
methods, condom use, and problems.
Concerns about HIV infection. Female: Age
at menarche, regularity, frequency, and
duration of periods, amount of bleeding;
bleeding between periods or after
intercourse, last menstrual period,
dysmenorrhea, premenstrual tension. Age
at menopause, menopausal symptoms,
postmenopausal bleeding. If the patient
was born before 1971, exposure to
diethylstilboestrol (DES) from maternal use
during pregnancy (linked to cervical
carcinoma). Vaginal discharge, itching,
sores, lumps, sexually transmitted
infections and treatments. Number of
pregnancies, number and type of deliveries,
number of abortions (spontaneous and
induced), complications of pregnancy,
birth-control methods. Sexual preference,
interest, function, satisfaction, any
problems, including dyspareunia. Concerns
about HIV infection.