History taking and

Physical Examination
 Health History
Set of subjective data that provides a
complete picture of the patient’s health
Evokes information on factors affecting the
condition
Initiates a non-judgmental, trusting
interpersonal relationship with the patient
Reflects responses that a patient may
assess his way of life
 Health History
Serves as a screening tool for abnormal
symptoms, health problems and concerns
as it records ways of responding to the
health problems
 Physical Examination
Obtains baseline information
Supplements, confirms, or refutes data
obtained in the health history
Obtains data that will help the nurse
establish nursing diagnoses in order to
plan the patient’s care;
Evaluates the physiologic outcomes of
health care
Screens for the presence of cancer
 Components of the History
Biographic Data
 client’s name, address, age, sex, race, marital
status, occupation, religious orientation,
health care financing, usual source of medical
care
Chief Complaint (s)
 Reason for seeking consultation
 Quote the patients own words
 Elaborate the chief complaint by asking open
ended questions
History of Present Illness
 Complete, clear and chronologic account of
problems prompting the patient to seek care
 Describes how each symptom developed
 Includes patient’s thoughts and feelings about
the chief complaint
 May include medications, allergies, smoking,
alcohol intake, because these are frequently
pertinent to the present illness
Guide questions:
P-place(location)palliative/precipitative
Q-quality
R-radiation
S-setting/severity
T-time (onset, duration)
If with medication, what ,when ,how
Past History
 Childhood illnesses
 Adult illnesses (Medical, Surgical,OB-Gyne,
Psyche)
 Immunizations, Allergies, Medications
 BT
 Last medical visit, last diagnostic examination
Personal and Social History
 Alcohol consumption
 Smoking
 Use of prohibited drugs
 Interpersonal relationship
 Exercise
Menstrual History
 Menopause
 LMP
Marital and Sexual History
 OB – GP (TPAL)
 Obstetrical abnormalities
 Gynecologic History
 Sexual Activity (marital and extramarital)
Family History
 Grandparents
 Father
 Mother
 Siblings
 Offsprings
If needed:
 Environmental History
 Travel History
Review of Systems
 A review of all health problems of body
systems that prevents the omission of data
NOT related to the HPI
 Considered as a subjective data
 Review of Systems
General
Skin
HEENT
Neck
Breasts
Respiratory
Cardiovascular
Gastrointestinal
 Review of Systems
Urinary
Genitals
Peripheral Vascular
Musculoskeletal
Neurologic
Hematologic
Endocrine
Psychiatric
 General Principles in PE
Reflect approach to the patient
Decide the scope of examination
 Comprehensive or focused
Choose the examination sequence
 Head-to-Toe approach
 Major-Body-Systems approach
 Problem-oriented approach
 General Principles in PE
Adjust the lighting and the environment
Prepare equipment
Make the patient comfortable
 Standard Precautions
Wash hands
Wear clean gloves
Wear mask and eye protection
Wear a gown
Practice infection control
Follow hospital SOP’s
Take care of used linens
Prevent injuries due to blood-borne pathogens
Practice proper isolation procedures
Methods of Physical Examination
Inspection
 Systematic
 General survey
 Used to assess color, rashes, scars, facial
expression
 Requires good lighting, adequate exposure
and occasional use of instruments
Methods of Physical Examination
Palpation
 Uses the sense of touch
 Assesses texture, temperature, moisture,
size, swelling, vibration, pulsation, rigidity or
spasticity, crepitation, tenderness
 Palpation
Fingertips
 Fine tactile discrimination
Grasping action of the fingers and thumb
 Detects position, shape, consistency
Dorsa of hands and fingers
 temperature
Base of fingers (MCP joints)
 Vibrations and crepitations
 Types of Palpation
Light palpation
 Should always precede deep palpation

Deep palpation
 Usually done bimanually
 Avoid injury or pain

Effectiveness depends on:

 Patient’s comfort/relaxation
 Starting palpation in areas that are not painful
 Percussion
Tapping the patient’s skin with short, sharp
strokes
Maps location and size of an organ
Signals density
Detects an abnormal mass if fairly
superficial
Elicits pain if underlying structures are
inflamed
 Five percussion Notes
Percussion Note Amplitude Pitch Quality Duration Sample
Location
Resonant Medium-Loud Low Clear, hollow Moderate Over normal
lung tissue

Hyperresonant Louder Lower Booming Longer Normal over

child’s lung
Abnormal in
adults, over
lungs with
increased
amount of air
(emphysema)
Tympany Loud High Musical and Sustained Over-filled
drum-like longest viscus (stomach,
intestines)

Dull Soft High Muffled thud short Relatively dense

organs
(liver, spleen)

Flat Very soft High A dead stop of Very short When no air is
sound, absolute present (thigh
dullness muscles, bone or
lumps)
 Auscultation
Directly or indirectly listening to sounds
produced by the body
Describe pitch, intensity, duration, and
quality
 Characteristics of a Good
Stethoscope
Tubing should be of thick material with an
internal diameter of 4 mm and a length of
12-14 inches
Earpieces should fit snugly
Should have a bell and a diaphragm
Eliminating Confusing Artifacts
Room must be quiet
Room should be warm- avoid involuntary
muscle contractions
Warm endpiece
Wet hairy areas
Endpiece should touch directly the
person’s skin
Avoid your own artifact
General Survey
 Physical Appearance
Age
Sex
Loss of consciousness
 Lethargic/somnolent
 Obtunded
 Stupor/semi-coma
 Coma
 Delirium
Skin Color
Facial features
 Body Structure
Stature
Nutrition
Symmetry
Posture
Position
Body build and contour
 Mobility
Gait
Range of Motion
 Behavior
Facial expression
Mood and affect
Speech
Dress
Personal hygiene
Skin, Hair, Nails
 Skin
Pigmentation
Temperature
Moisture
Texture
Thickness
Mobility and turgor
 Hair
Evenly distributed
Silky, resilient hair
No infection or infestation
 Nails
Convex curvature or flat
Bed color
Capillary refill
 Dermatology:
Primary and Secondary
Lesions
 Dermatological Lesions
Primary lesions
Secondary lesions

May be described in terms of 5 features:

 Size
 Shape
 Contour
 Color
 characteristics
 configuration

annular herpetiform
linear
Configuration: clustered
Configuration: linear
Configuration: target-shaped
 Distribution:
where on the body?

scalp

periumbilical

elbows
 Common distributions
Generalized
acral (hands and feet)
palms and soles
unilateral/bilateral
symmetrical/asymmetrical
etc
 color

erythematous

violaceous

reddish-brown
color: violaceous (lichen
planus)
color: blue-black (blue nevus)
color: beefy red (lymphoma)
 pigmentation

hyperpigmented

hypopigmented

depigmented
Hyperpigmentation: melanoma
Hypopigmentation: vitiligo
Atrophy: loss of tissue
atrophy: lipodystrophy
Atrophy of hair: alopecia areata
Hypertrophy: increased tissue
Hypertrophy: keloid
 texture, consistency
soft, hard
Fluctuant
velvety, rough
Indurated
Moist
fleshy, flabby
rubbery
Consistency: rock hard keloids
Primary Lesions
 Primary Lesions
Applies to the original lesion which may
eventually evolve into secondary lesions
E.g. a blister developing into an erosion
and becoming encrusted in herpetic
infection
 Macule
“a spot”
less than 1 cm in diameter

10 millimeters
Macule
hypopigmented macules
 Patch
“a spot”
larger than 1 cm in diameter

1 cm
patch: nevus flammeus
 Papule
“bump”
less than 1 cm.
Papule
Papules:molluscum
contagiosum
papule: melanocytic nevus
papules: pseudofolliculitis
barbae
papules: venereal warts
 Plaque
broad, raised bump
or confluence of bumps
Plaque
plaque: psoriasis
 Nodule
“bump or lump”
larger than 1 cm

1 cm
nodule: granular cell tumor
 Vesicle
“fluid-filled bump”
less than 1 cm.
vesicle
vesicles: herpes simplex
 Wheal
a papule or plaque
due
to transient tissue
edema
wheal: urticaria
 Bulla
a vesicle larger
than 1 cm in diameter

1 cm
Bulla: insect bite reaction
 Pustule
vesicle or bulla filled with pus
pustule: furuncle
Secondary Lesions
 Erosion
superficial loss of epidermis

epidermis

dermis
erosions: Hailey-Hailey disease
 Ulcer
focal loss of epidermis and part or all of dermis;
heals with a scar

epidermis

dermis
ulcer: leishmaniasis
 Fissure
narrow, linear loss of epidermis/dermis

epidermis

dermis
fissures: condyloma
accuminatum
Head and Neck
 Skull
Size and shape
Temporal area
Hydrocephaly vs Anencephaly
 Face
Facial structures
Symmetry
Facial Asymmetry
 Neck
Movement
 No pain on movement
Lymph nodes
 No palpable
Trachea
 Midline
Thyroid gland
 Not enlarged
Anterior Neck Mass
 Eyes
Test visual acuity
Test extraocular muscle movements
Eyelids: no swelling
Eyelashes: not matted
Eyeballs: no eye protrusion
Conjunctiva: pink
Sclera: anicteric
 Eyes
Cornea/Lens: clear
Iris: pigmented
Pupils: PERRLA
Exophthalmos
 Ears
External Ear: not hyperemic, no swelling, no
discharge, no tragal tenderness
Test hearing acuity: Weber and Rinne tests
Normal TM vs Otitis Externa
 Nose
Symmetric
Non tender sinuses
Nasal septum midline
Clean watery discharge
Nasal lesion
 Mouth
Lips: no cracking, no lesions
Teeth: no diseased, absent or loose tooth
Tongue: pink and even
Buccal mucosa: pink, soft, moist
Palate:
 Ant hard palate: white
 Post hard palate: pink
Uvula: midline
 Throat
Tonsils: not enlarged
Enlarged Tonsils
Breasts, Axilla,
Regional
Lymphatics
 Breasts
Smooth
Symmetric
Areola: round or oval, bilaterally the same
Nipple: symmetric, protruding, flat, or
inverted
Breast Asymmetry and Mass
 Axilla
No palpable lymph nodes
Thorax and Lungs
 Posterior Chest
No deformities
Antero-posterior diameter should be less
than the transverse diameter
Resonant
Equal tactile fremitus
Symmetrical chest expansion, no
retractions, clear breath sounds
 Anterior Chest
Same as posterior chest
No use of accessory muscle
Barrel Chest
 Neck Vessels
Carotid arteries: ++ pulses
Rapid upstroke, slower downstroke
No bruit
JVP: 4.5 cm at 45 degrees
 Precordium
Adynamic
Apical beat at 5th left intercostal space,
midclavicular line
S1>S2 at the apex, S2>S1 at the base
No heaves and lifts
No murmurs
 Grading Murmurs
Grade I- barely audible
Grade II- clearly audible, but faint
Grade III- moderately loud, easy to hear
Grade IV- loud with thrill
Grade V- heard with stethoscope lifted off
the chest wall
Grade VI- heard without stethoscope
 Describing Murmurs
Pitch- high, medium, low
Pattern- crescendo, decrescendo
Quality- musical, blowing, harsh or
rumbling
Location- area of maximum intensity
Radiation
Posture
Abdomen
 Abdomen
Inspection: mass, lesions, scars,
discolorations, abnormal blood vessels
Auscultation: Bowel sounds (Hypoactive,
Normoactive, Hyperactive)
Percussion: Tympanitic
Palpation: No masses, No organomegaly,
no tenderness on direct and rebound
palpation
Enlarged Abdomen
Genitals and Anus
 Genitals
No mass, no lesions
Female Genital lesions
Male Genital lesions
 Anus
External: No mass, no lesions
With or without skin tags
Internal: Smooth rectal vault
No tenderness
Color of stool on tactating fingers

In males: may palpate for prostate

Hemorrhoids
Thank you very much!!!