Medical History and Physical

Examination Rapid Review

 Components of Medical History
 Identifying Data (ID)
 Chief Complaint (CC)
 History of Present Illness (HPI)
 Past Medical History (PMH)
 Current Health Status (CHS)
 Psycho Social History (PSH)
 Family History (FH)
 Review of Systems (ROS)

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 Identifying Data (ID)
Name or initials
Date of birth
Medical record number

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 Chief Complaint (CC)
 One-liner--why patient here--use patient's own
words
 How to write--patient’s age, occupation or sex,
problem & duration

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 History of Present Illness (HPI)
Story of patient’s chief complaint (CC)
Story of any active/significant illnesses patient as
which impact on HPI

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 History of Present Illness (HPI)
Story of CC:
logical
complete
chronological

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 History of Present Illness (HPI)
Story of CC (How To Ask):
start with open-ended questions
fill in with focused questions

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 History of Present Illness (HPI)
Story of CC
Describe symptoms in terms of:
– location
– quality
– quantity (severity)
– timing
– setting
– aggravating and/or alleviating factors
– associated manifestations

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 History of Present Illness (HPI)
Story of CC
document:
– prior medical Dx/Rx
– significant positives or negatives

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 History of Present Illness (HPI)
Story of CC
Document patient’s understanding of his/her illness:
– patient’s fears and concerns
– impact of illness/treatment on patient, family

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 History of Present Illness (HPI)
Story of CC
• logical, complete, chronological
• open-to-closed questioning
• characterize symptoms
• document:
– prior medical diagnoses/treatments
– significant positives/negatives
• patient's understanding of illness
Story of any active/significant illnesses patient has
which impact on HPI

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 Past Medical History (PMH)
Childhood illnesses
Immunizations
Adult illnesses
Psychiatric illnesses or Hospitalizations
Operations
Injuries/accidents
Obstetric history
Transfusions

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 Adult Illnesses
Dx & how made
Rx
Response & sequelae

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 Operations
Why
Kind
When & sequelae

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 Obstetric History
Number times pregnant
Number live births
Number abortions (spontaneous/induced)

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 Transfusions
Where
When
Why
Reactions/complications

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 Current Health Status (CHS)
Current medications--name, dose, reason, SE
Allergies/drug reactions
Health screening
Diet/sleep/exercise
Habits--tobacco, alcohol, elicit
Alternative Therapies

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 Psycho-Social History (PSH)
Marital status
Living conditions
Employment
Sexual history
Significant life events
Mental status

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 Family History (FH)
Mother/father/siblings/children
• age--health (if dead, why)
Significant illnesses that run in family

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 Review of Systems (ROS)
Characterize patient's overall health status
Review systems/symptoms from head to toe

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 Physical Diagnosis
• Goal of Physical Examination?
• How do I approach the patient
• Conducting general survey--
• What am I looking for?
• Vital Signs and why?
• How do I record all this information?
• Organization of thoughts?

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 The Four Cardinal Principles of
Physical Examination:
• Inspection
• Palpation
• Percussion
• Auscultation
– “teach the eye to see, the finger to feel, and the ear to
hear”---Sir William Osler
– (what is the fifth?)

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 Maintain a “watchful eye” during the
medical interview
• General Survey--Note:
• Level of Consciousness
• Apparent State of Health---General appearance--
Age Appropriate?
• State of Nutrition--Wasting?,…..
• Body Habitus

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 Watchful eye---
• Grooming, Hygiene----children/ elderly--?neglect---
-home/environment?
• Odors---ETOH?---ACETONE?
• Symmetry---extremities disproportionate to
trunk?….Body Markings?
• Posture and Gait….Limp?/ Upright? Unbalanced?
Pace?
– Can be noted as patient walks towards exam room

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 Watchful eye and Ear-----
• Speech
• Facial Expressions…fear?/ stoic?
• Appropriate facial responses to communication?

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 Signs of Distress?
• Address early on-----Note posture, Labored
Breathing? Sweating? Trembling….Chills?
Wincing?….Pain

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 Preparing For The Exam
• Lighting
• Equipment
• Universal Precautions
• Patient Comfort

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The Science of Physical Examination
• Vital Signs
Blood Pressure (BP) --Arterial blood
pressure is lateral pressure exerted by a
column of blood against the arterial wall
• It is result of cardiac output & peripheral
vascular resistance

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BLOOD PRESSURE

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Arterial pressure
Arterial pressure
 is pulsatile
 is not constant during a cardiac cycle

1. Systolic pressure
 is highest arterial pressure during a cardiac cycle
 is measured after heart contracts (systole) and blood is
ejected into arterial system

2. Diastolic pressure
 is lowest arterial pressure during a cardiac cycle
 is measured when heart is relaxed (diastole) and blood is
returned to heart via veins

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Arterial pressure (2)
3. Pulse pressure
 is difference between systolic and diastolic pressures
 most important determinant of pulse pressure is stroke
volume
 As blood is ejected from left ventricle into arterial system, arterial
pressure ↑ b/c of relatively low capacitance of arteries
 b/c diastolic pressure remains unchanged during ventricular
systole, pulse pressure ↑ to same extent as systolic pressure
 ↓ in capacitance, such as those that occur with aging process,
cause ↑ in pulse pressure

4. Mean arterial pressure

 is average arterial pressure with respect to time
 can be calculated approximately as diastolic pressure plus one-
third of pulse pressure 31
What’s The Difference???-better yet What
does it all mean?

• Systolic BP = The Peak Pressure in arteries,

regulated by Stroke Volume (SV) and compliance
of the blood vessels
• Diastolic BP = lowest pressure in arteries,
dependent on peripheral vascular resistance

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 Techniques of Exam--BP
• Which Cuff?…..Appropriate size.
• What if I get a different reading in one arm
vs. other?
• Right arm BP--5-10mm> than left
• Systolic BP in legs 15-20mm> than in arms
Poiseuille’s Law: relates to fact that total
resistance of vessels connected in parallel is
greater than resistance of a single large vessel

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 Techniques of Exam-BP
• How to Assess?
• Normal Values & Changes from the
Norm?…Adult, Infant, Pregnancy, Geriatric...
• Clinical Significance?…Elevation-Hypertensive,
…Low-Hypotensive…Orthostatic Changes

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 Techniques of Exam--Pulse

• Pulse= denotes the heart rate & rhythm,

condition of the arterial walls
• How to Assess?
• What do my readings tell me? Rapid?
Slow?

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 Vital Signs… Respiratory Rate

• Assessment and Techniques of exam?- *Assess

w/o the patient being aware.
• What is the Rate and Pattern? Increased rate-
(Tachypnea),? Increased Depth-(Hyperpnea)?
Cheyne-Stokes?….etc

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 Vital Signs
• Clinical significance:
• Temperature
• Weight
• Height

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 How do I write it all down?
• Complete Hx w/ ROS & PE + Labs.
• S.O.A.P Formats
• Problem Specific
• Maintaining Organization
• Remembering It All---Note as you go along---Less
lost Data
• Hospital Records, Specified Forms (Clinics,
Hospitals etc.)
• EHR (Electronic health record)
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 THE END

See next slide for links to tools

and resources for further study.

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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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