HISTORY TAKING

Alrik Earle T. Escudero

SIGNIFICANCE
Obtaining an accurate history is the critical

FIRST STEP in determining the ETIOLOGY of

a patients problem
A large percentage of the time (70%), one
will be able to make a diagnosis on history
alone

General Approach
Introduce Yourself
Try and See things from patients point of

view.
Understand patient underneath mental
status, anxiety, irritation or depression
Always exhibit neutral position
Listen Carefully
Questioning: simple, clear avoid medical
terms, use open leading questions

General Data
Name
Age
Address
Sex
Ethnicity
Occupation
Religion
Marital Status
Date of Examination

Complete History
Chief Complaint
History of Present Illness
Past Medical/Surgical History
Family History
Personal/Social History
Menstrual History
Sexual History
Obstetrical History
Review of Systems

Chief Complaint
Why did the patient seek care?

History of Present Illness

1.

Complete description of first symptoms

Provokes causative, relieving, exacerbating factors
Quality
Pain: sharp, dull, stabbing, burning, crushing
Radiates
Primary location
Area where it radiates
Localization
Severity (0 10)/Intensity/Progression
Time
Onset
Duration
Persistence
Number of occurences
2. Medications (include dosage)
3. Results of previous laboratory work-up
4. Results of previous ancillary procedures
5. State of health just before onset of problem
6. What led the patient to seek consult?

Past Medical History

1. Illnesses
Hypertension
Allergy Gout/arthritides
Heart disease
Asthma Stroke
Diabetes mellitus Tuberculosis Seizures
Thyroid disease Blood dyscrasias Cancer
2. Allergies
Food
Environmental exposures
Adverse drug reactions
3. Medications
Current
Frequently
Herbal
4. Previous hospital admission
5. Previous injury
6. Previous surgery
7. Previous blood transfusion

Family History
1. Allergy
2. Asthma
3. Tuberculosis
4. Gout/Other arthritides
5. Blood dyscrasias
6. Cancer
7. Diabetes mellitus
8. Heart diseases
9. Hypertension
10. Stroke
11. Mental illness
12. Others

Personal And Social History

1. Habits
Smoking history
Alcohol
Substance use/abuse
2. Nutrition
Diet
Source of water
3. Sleep pattern
4. Exercise
5. Living arrangement
6. Source of income
7. Support system

MENSTRUAL HISTORY
1. Menarche age/Menopause age
2. Menstrual flow
Interval
Duration
Amount
Symptom (Dysmenorrhea)
3. LMP
4. PMP

Sexual History
1. Coitarche
2. # of sexual partners
3. Symptoms (Dyspareunia, post coital

bleeding)

Obstetrical History
1. Obstetrical score
Gravidity, Parity
Term, Preterm, Abortion, Living
2. Details of previous pregnancy
Year, manner, and outcome of delivery
3. Family planning method/s
4. Prenatal check-ups for current pregnancy

Review of Systems
GENERAL:(-) weakness, (-) fatigue, (-) febrile (-) weight

gain/loss
SKIN: (-) pruritus, (-) dry skin, (-) bruises, (-) rash, (-)

photosensitivity
EAR: (-) deafness, (-) tinnitus, (-) discharge
NOSE: (-) epistaxis, (-)discharge, (-) obstruction, (-) post-nasal

drip, (-) sinusitis

MOUTH: (-) bleeding gums, (-) sores, (-) fissures,(-) tongue

abnormalities, (-) dental caries

THROAT: (-) soreness, (-)tonsillitis
NECK:No stiffness, limitation of motion, masses, (-) sensation

of lump in throat
BREAST: No masses, discharge, trauma
PULMONARY: (-) dyspnea, no cough, sputum production,

Review of Systems
CARDIOVASCULAR: No chest pain, (-) PND, (-) orthopnea, (-) syncope, (-)

edema, (-) phlebitis, no varicosities, claudication

GENITOURINARY: (-) hematuria, dysuria, bubbly urine, flank pain
Musculoskeletal: (-)pain, (-) weakness in lower extremities, wasting,

trauma, abnormal posture

Endocrine: No heat or cold intolerance, voice change, polyuria,

polyphagia, polydypsia
Hematopoietic:(-) Easy bruisability, pallor, no adenopathy, no gum

bleeding
Neurologic: No headache, seizure, sensory perversion, motor

dysfunction, speech disturbance, mental changes, head trauma

Psychiatry: No anxiety, depression, interpersonal relationship difficulties,

illusion, delusion, hallucination, paranoia

PHYSICAL EXAMINATION

Alrik Earle T. Escudero

General Survey
General appearance, posture (relaxed, rigid, restless), grooming
Describe general state of health (well, acutely ill or chronically ill)
Level of comfort

Comfortable or in distress
Distress: speaks in phrases, tripod, orthopnea, squatting
Level of consciousness (Conscious, sedated, drowsy)
Ambulatory status (Ambulatory/with assistance/Wheelchair/Bedridden)
Body habitus
Hyposthenic/ectomorphic
Sthenic/mesomorphic
Hypersthenic/endomorphic
Facies
Moon facies
Stare of hyperthyroid

Vital Signs
Blood Pressure
Proper measurement of sphygmomanometer
Width = 40% of upper arm circumference (12 to 14 cm)
Length = 80% of upper arm circumference
Apply cuff 2.5 cm above the antecubital fossa

Slowly deflate the cup by 2 to 3 mmHg/second. State the

reading on the manometer when the first Korotkoff sound is

heard as the auscultatory systolic BP. Continue to deflate slowly
by 2 to 3 mmHg/second and note level on the manometer when
Korotkoff sound disappears as the diastolic BP (phase 5).
Classification of blood pressure:
Heart Rate
Respiratory Rate
Temperature
Pain Scale

Vital Signs
Heart Rate
Use index and middle fingers to palpate for radial artery

pulse.
Count pulse rate for one full minute.
Note rhythm: regular or irregular. Note volume.
Respiratory Rate (Note

number of rise/fall (cycles)

of the vest for 1 full minute)
Normal: regular and comfortable at a rate of 12 to 20
per minute.
Bradypnea: < 12 breaths/minute vs. Tachypnea: > 20
breaths/minute

Temperature
Pain Scale

Anthropometrics
BMI = Weight in kilograms/(Height in

meters)2

Exam of the Skin

Examine the patient in good lighting
Inspect and palpate skin for the

following:
Color

Pigmentation

Texture

Turgor

Lesions

Hair distribution

Warmth: use back of hand

Moisture

Abnormal Findings

Pigmentation

Color

Pallor:
Iron def. anemia
Yellow:
Jaundice
Carotenemia
Hemolysis
Red:
Erythroderma

Hyper

pigmentation
Localized:
Pregnancy
BCP ingestion
Generalized:
Thyrotoxicosis
Liver disease
Renal disease
De-pigmentation:
Vitiligo
Injury

Abnormal Findings

Turgor

Texture
Soft: (Thyrotoxicosis)
Tight: (Scleroderma)
Rough:

(Hypothyroidism)
Moisture
Dry: (Vitamin A def,

Myxedema)
Oily: (Acne)

Decreased:

(Dehydration)
Warmth:
Generalized warmth:

(Fever, Hyperthyroidism)
Localized warmth:
(Inflammation)
Coolness:
(Hypothyroidism,
Frostbite, Hypothermia,
Shock, Low cardiac
output)

MOLE WARNING SIGNS

The "ABCD" rule & Melanoma
Danger Signs

Asymmetry
Unequal or asymmetric moles are

suspicious.

Border
If the border is irregular or indistinct,

it is more likely to be cancerous (or

precancerous)

Color
Variation of color (e.g., more than one

color or shade) within a mole is a

suspicious finding

Diameter
Any mole that has a diameter larger

than a pencil's eraser in size (> 6 mm)

should be considered suspicious.

Elevation
If a mole is elevated, or raised from of the

skin, it should be considered suspicious

HEENT
Head and Scalp
Note hair color, quantity, distribution, and texture.
Note presence of seborrhea or lesions.

Eyebrows
note symmetry, loss/extraordinary hair growth, presence of seborrhea

Eyelids
note symmetry, matting or loss, crusting, redness, swelling

Eyes
note position, alignment, symmetry, size, shape

Conjunctivae and Sclera

Instruct patient to look up.

Pull down lower lid of each eye to expose inferior sclera and conjunctiva.
Using a penlight, inspect sclera and conjunctiva of upper eyeball for color,
vascularity, and swelling. Do the same for the other eye.
Tests pupils for reactivity to light, both direct and consensual as well as
accommodation

Ear
Inspect and palpate external ear for

deformities, tenderness.
Inspect for wax, discharge, foreign bodies,
redness, and swelling.
Inspect tympanic membrane for the following,
note normal findings:
Color: transluscent, pearly gray color

Landmarks: umbo, handle of malleus, light reflex

Contour: slightly conical with concavity at the
umbo
Perforations: none

Nose
Visually inspect and palpate nose for

deformity, symmetry, inflammation.

Elevate tip of nose with neck
hyperextended.
Bilaterally inspect nasal mucosa.
Inspect nasal septum.

Mouth
Inspects lips, gums, teeth, tongue, floor

of
the mouth, and posterior pharynx.
Instruct patient to open mouth.
With tongue blade and penlight visually
inspect hard and soft palate, buccal
mucosa, gingiva, teeth, and tongue.

Lymph Node Palpation

Palpate with pads of

all four fingertips

Examine both sides
simultaneously
Use steady gentle
pressure
The major lymph node groups are located along

the anterior and posterior aspects of the neck

and on the underside of the jaw

Cervical Nodes

Exam of Lymph Nodes

Lymph nodes are part of immune

system
Lymphadenitis
Firm
Tender
Enlarged
Warm
May remain enlarged after infection
Less than 1 cm
Nontender

Malignancies
Firm
Non-tender
Matted (i.e. stuck to each other)
Fixed (i.e. stuck to underlying

tissue
Increase in size over time

Common Causes of
Lymphadenitis
Pharyngitis or dental infections
Diffuse upper airway infections
Mononucleosis
Systemic infections
Tuberculosis
Inflammatory processes
Sarcoidosis

Examination of the Thyroid

Inspection
Gland lies

approximately 2-3 cm
below the thyroid
cartilage
Either side of the
tracheal rings, which
may or may not be
apparent on visual
inspection.

Palpation
Stand behind the patient and

place the middle three fingers

of both hands along the
mid-line of the neck, just
below the chin

identify and feel the structures from the

front before performing the exam from

behind

Slide the three fingers of both hands to either

side of the rings

Have the patient drink water as you palpate

If enlarged, is it symmetrical
Unilateral vs. bilateral
Discrete nodules within either lobe?
Gland feels firm
is it attached to the adjacent structures?

(i.e. fixed to underlying tissue..

consistent with malignancy)

freely mobile?

(i.e. moves up and down with

swallowing)

Findings of Exam of Thyroid

Consistency of gland
Consistency of muscle tissue
Unusual hardness
Cancer or scarring
Softness, or sponginess
Toxic goiter
Tenderness
Acute infections
Hemorrhage into the gland

ANTERIOR THORAX, LUNGS

Assesses symmetry of lung expansion
(inspection and palpation).

Palpates for any tenderness in the

chest wall and performs tactile fremiti.

Percusses anterior lung fields.
Auscultates anterior lung fields.
Use diaphragm of stethoscope.
Note: vesicular, bronchovesicular, broncho-

tracheal

JVP and Carotid Pulse

Inspects neck veins and identifies highest

undulation of the right internal jugular vein

and measures JVP at 30 or 45 degree
angle.
Palpates for carotid artery pulse (one at a
time) and describes.
Note: Amplitude: 0 = absent, +1 =
diminished, +2 = normal, +3 = full,
increased, +4 =bounding
Contour: normal = smooth, rounded, domed
Upstroke and downstroke

Cardiovascular
Inspects precordium and reports its

dynamicity (adynamic, dynamic,

hyperdynamic)
Palpates precordium and describes apex
beat (location, diameter, amplitude,
duration in relation to systole)
Palpates for LV or RV heaves, LA or RA
lifts, abnormal pulsations over 2nd ISC
RPSL, and thrills.
Mitral valve: apex beat (5th ICS), LMCL
Tricuspid valve: left lower sternum
Pulmonic valve: 2nd ICS LPSL

Examination
of the
Abdomen

General Considerations
Patient should have an empty

bladder.
Supine on the exam table and
appropriately draped.
Examination room must be quiet to
perform adequate auscultation and
percussion.
Watch the patient's face for signs of
discomfort during the examination

Disorders in the chest will often

manifest with abdominal symptoms

It is always wise to examine the

chest when evaluating an abdominal

complaint
Inguinal/rectal examination in

males
Pelvic/rectal examination in

Anatomical
Locations

Inspection
Scars, striae, hernias, vascular
changes, lesions, or rashes
Movement associated with
peristalsis or pulsations
Abdominal contour
Flat, scaphoid, or
protuberant?

Auscultation
Place the diaphragm of

stethoscope lightly on the

abdomen
Listen for bowel sounds
normal
increased
decreased
absent

Listen for bruits over the

renal arteries, iliac arteries,
and aorta

Percussion
Percuss in all four quadrants
Categorize what you hear as tympanic or

dull.
Tympany is normally present over most

of the abdomen in the supine position.

Unusual dullness may be
a clue to an underlying
abdominal mass

Liver Span
Percuss downward from the

chest in the right midclavicular

line to detect the top edge of
liver dullness.
Percuss upward from the
abdomen in the same line to
detect the bottom edge of liver
dullness.
Measure the liver span between
these two points. This
measurement should be 6-12 cm
in a normal adult.

Splenic Dullness
Percuss the lowest costal

interspace in the left

anterior axillary line
This area is normally

tympanic.
Ask the patient to take a deep

breath and percuss this area

again
Dullness in this area is a

sign of splenic
enlargement.

General
Palpation
Light palpation
Areas of tenderness
Most sensitive indicator is patients facial
expression
Watch the patients face, not your

hands
Voluntary or involuntary guarding may be present

Deep Palpation
Identify abdominal masses or areas of deep
tenderness

Palpation of the Liver

Place the fingers just below the

right costal margin and press

firmly.
Ask the patient to take a deep
breath.
You may feel the edge of the liver
press against your fingers
Or it may slide under your

hand as the patient exhales.

A normal liver is not tender

Palpation of the Aorta

Press down deeply in

the midline above the

umbilicus
The aortic pulsation is
easily felt on most
individuals
A well defined, pulsatile
mass, greater than 3 cm
across, suggests an
aortic aneurysm.

Palpation of the Spleen

Use the left hand (posteriorly) to

lift the lower rib cage and flank

Press down just below the left
costal margin with the right hand
Ask the patient to take a deep
breath
The spleen is not normally
palpable on most individual

Special
Tests

Rebound Tenderness
Test for peritoneal irritation
Warn the patient
Press deeply on the abdomen

o After a moment, quickly

release pressure
o If it hurts more upon
release, the patient has
rebound tenderness

Costovertebral Tenderness
+CVA is associated with renal disease
Warn the patient what you are about to

do
Have the patient sit up on the exam

table
Use heel of your closed fist to

strike the patient firmly over

costovertebral angles

Shifting Dullness
Test for peritoneal fluid (ascites)
Percuss the abdomen to outline areas of

dullness and tympany

Have the patient roll away from you

Percuss again
If dullness has shifted to
areas of prior tympany,
patient may have excess
peritoneal fluid

Psoas Sign
Have patient lie on left side
Place your left hand on patients

right hip
Extend the right thigh while

applying counter resistance

Increased abdominal pain indicates

a positive psoas sign

Obturator Sign
Raise the patient's right leg with the knee flexed
Rotate the leg internally at the hip
Increased abdominal pain indicates a

positive obturator sign

Murphy Sign
Place palpating fingers beneath the right

costal arch just below the hepatic margin

Ask the patient to take a deep breath
While patient is inhaling, press fingers
deeply beneath the arch
Interruption of inhalation = positive
Murphys sign = Cholecystitis (RUQ)

Rectal Examination
Inspect perianal area for skin tag, lesions, external

hemorrhoids, lumps, opening of fistula.

Perform digital examination:
Wear gloves on right hand and lubricate index
finger
Insert lubricated finger gently into the anal canal
pointing toward the umbilicus
Note for anal sphincteric tone
Palpate anus on 4 quadrants and note for: mass,
tenderness, internal hemorrhoids,
prostate size, consistency, tenderness, nodule,
cervix, blood on examining finger

THANK YOU!