INTRODUCTION TO

PHYSICAL DIAGNOSIS:
PHYSICAL EXAMINATION
AND HISTORY TAKING
Ralph Raoul A. Villamor, MD
Diplomate in Internal Medicine
Faculty, Department of Physical Diagnosis
Southwestern University School of Medicine
INTRODUCTION:
 Gathering a sensitive and nuanced
history
 Performing a thorough and accurate
examination
 Integrating essential elements of
clinical care
 Identifying symptoms, and abnormal
findings
 Linking findings to underlying
pathophysiology
PATIENT ASSESSMENT:
DETERMINING THE
SCOPE OF YOUR
ASSESSMENT!!!
Comprehensive VS Focused,
which is appropriate???
 COMPREHENSIVE
FOCUSED
 For new patients in the office or  For established patients
hospital
 Address focused concerns or
 Fundamental personalized symptoms
knowledge
 Symptoms restricted to a
 Strengthens the clinician – specific body system
patient relationship
 Applies examination methods
 Provide baseline relevant to assessing the
concern or problem as precisely
 Creates platform for health
and carefully as possible
promotion
 Develop proficiency in skills
SUBJECTIVE VS OBJECTIVE
DATA
 What’s the difference?
 Is it important?
SUBJECTIVE VS
OBJECTIVE
 What the patient tells you  What you detect during the
examination
 The history
 All physical examination
 Chief complaint
findings
 Review of systems

 Eg. Mrs. A, reports to you of

 Eg. Mrs. A, is an older,
pressure over her left chest overweight female, BP 150/90
“like an elephant is sitting mmHg, HR of 90 bpm, RR: 24
there” cpm
SUBJECTIVE
OR
OBJECTIVE??
 Body malaise
 Abdominal pain
 Weight of 90 kg
 Pale palpebral
conjunctivae
 Difficulty in urinating
 Itchiness
 Bounding radial pulses
 dyspnea
COMPREHENSIVE ADULT
HEALTH HISTORY:
SEVEN COMPONENTS
 Initial information: Identifying
data and source of history;
reliability
 Chief compliant(s)
 Present Illness
 Past history
 Family history
 Personal and Social history
 Review of systems
1. INITIAL INFORMATION:
 Identifying data  age, gender, occupation, marital status
 Source of the history  patient, family member, friend, letter of referral
 Reliability  varies accdg to memory, trust, mood
2. CHIEF
COMPLAINT
 The one or more symptoms
or concern causing the
patient to seek care
 “quote the patient’s own
words”
 Report their goals instead if
with no complaints
INITIAL INFORMATION AND
CHIEF COMPLAINT:
 Source of history: patient
 Reliability: 100%

 Mrs. P.A., 48 years old, Female, Filipino, Married, a

Roman catholic, presently residing in Sambag 1,
Urgello, Cebu City, working as a faculty in a
medical school, sought admission at SWU-MC on
August 7, 2019 at 8:00AM

 Chief complaint: painful urination

3. PRESENT ILLNESS:
 Always follow 3 Cs: Complete! Clear!
Chronological!
 Symptoms well characterized by seven (7) attributes
 Location
 Quality
 Quantity or severity
 Timing (onset, frequency, duration)
 Factors that aggravated / relieved symptoms
 Associated manifestations

 Pertinent positives and pertinent negatives

3. PRESENT ILLNESS:
 1 day prior to admission, Mrs. P.A. noted pain during urination, it was
burning in character, with a pain score of 6/10, non radiating, with
associated blood tinge during the last part of urination. She also noted
increased frequency of urination. Patient self medicated with
paracetamol (biogesic) 500mg/tab, 1 tab 3 times a day with no relief of
symptoms. No consultation was done, patient tolerated her condition.
 6 hours prior to admission, patient still noted persistence of pain with
blood tinged urine but was now associated with fever with a
temperature of 38.8 C, chills and vomiting, which was not relieved by
intake of paracetamol.
 Persistence and worsening of her condition prompted her to seek
admission
3. PRESENT
ILLNESS
 Medications: name, dose, route,
frequency, home remedies, vitamins,
herbal supplements, oral
contraceptives
 Allergies: specific reaction to each
food or drug
 Tobacco use: amount, frequency,
duration, or quit?
 Alcohol and recreational drug use
3. PRESENT ILLNESS
 Mrs. P.A. noted drug allergies to ciprofloxacin
causing generalized itching with rashes all over her
body. She had no known food allergies
 She smokes 3 sticks of cigarette a day, usually after
meals, for 18 years.
 She is a non alcoholic beverage drinker and denies
history of illicit drug use
4. PAST
HISTORY
 Childhood illnesses
 Adult illnesses
 Medical
 Surgical
 Obstetric / gynecologic
 psychiatric

 Health maintenance
 Immunizations
 Screening tests
4. PAST HISTORY
 Childhood illnesses: Mrs. P.A. had no known childhood diseases, she
cannot recall her vaccination history when she was younger but stated
she had complete vaccinations.
 Medical: She is a known hypertensive, with maintenance medication of
amlodipine (amvasc) 10mg/tab, 1 tab once a day in the morning with
good compliance
 She was previously admitted for 3 days in SWU-MC on august 13,
2017 due to a urinary tract infection.
 Surgical: She had an appendectomy on July 12, 2018 at SWU-MC due
to an appendicitis, discharged without any complications
4. PAST HISTORY
 OB/GYN: Patient is a nulligravid, menarche at 13
years of age, duration of 3-4 days with regular
interval, using 2-3 pads per day. Coitarche at age 22
years and noted only one sexual partner. Barrier
method (condom) and withdrawal are the
contraceptives of choice.

 She has no known psychiatric illnesses

5. FAMILY
HISTORY
 Outline or diagram: age, health, cause
of death
 Review each of the following
conditions and record whether present
or absent
 Hypertension
 Diabetes
 Stroke
 Cancer
 Mental illness
 etc
5. FAMILY HISTORY
 Mrs. P.A. noted hypertension on the paternal side
including both her grandparents. Her mother died at
age 50 years due to stage 4 breast cancer. No family
history of diabetes, heart disease, cancer, nor
mental illness
6. PERSONAL AND
SOCIAL HISTORY
 Patients personality and interests
 Source of support, strengths, fears
 Occupation, schooling, home
situation
 Activities of daily living
 Lifestyle habits (exercise, diet)
6. PERSONAL AND SOCIAL
HISTORY
 Mrs. P.A. works as a faculty in the school of medicine, she
is teaching basic sciences stating her job is stressful but
rewarding. She finished her degree in medicine in the same
institution. Whenever she feels burnt out, her husband
would always comfort her. She has no formal exercise and
noted cleaning the house as her only exercise. Her diet
contains mostly of meat, preferably fried, rice, with no
regular intake of vegetable as she hates its taste. She
regularly drinks coffee 2 times a day in the morning and
during the afternoon.
7. REVIEW OF
SYSTEMS
 Yes or no questions
 From head to toe
 “The next part of the history may feel
like a hundred questions, but it is
important to make sure we have not
missed anything”
 May cover problems that the patient
overlooked
7. REVIEW OF SYSTEMS
 General  Peripheral vascular
 Skin  Urinary
 Head, eyes, ears, nose, throat  Genital
(HEENT)
 Musculoskeletal
 Neck
 Psychiatric
 Breast
 Neurologic
 Respiratory
 Hematologic
 Cardiovascular
 Endocrine
 Gastrointestinal
REVIEW OF SYSTEMS
 Skin: no rashes or other changes
 HEENT: no history of head injury, eyes: reading glasses for
3 years, no symptoms, Ears: hearing good, no tinnitus,
vertigo, Nose: no sinus trouble, Throat: no bleeding, last
dental visit 2 years ago.
 Neck: no lumps, no goiter, no pain
 Breast: no lumps, pain nor discharge
 Respiratory: no cough, shortness of breath
 Cardiovascular: no known heart disease, no chest pain,
palpitations nor dyspnea, with high blood pressure 140-90
mmHg
REVIEW OF SYSTEMS
 Gastrointestinal: appetite good, no nausea, no vomiting,
indigestion. Bowel movement once a day, no pain, no
jaundice
 Urinary: with dysuria, hematuria
 Genital: no vaginal discharge, no dyspareunia
 Musculoskeletal: no muscle nor joint pains
 Psychiatric: no history of depression or treatment for
psychiatric disorders
 Neurologic: no faintness, seizures, nor motor loss. Memory
good
THE COMPREHENSIVE
ADULT PHYSICAL
EXAMINATION
 Reflect on your approach to the
patient
 Adjust the lighting and the
environment
 Check your equipment
 Make the patient comfortable
 Choose the sequence of examination
REFLECT ON YOUR
APPROACH TO THE
PATIENT
 Identify yourself as a student
 Forgetting parts of the
examination are common
 Avoid interpreting your findings
ADJUST THE LIGHTING AND
THE ENVIRONMENT
 “set the stage”
 Good lighting and a quite environment
 Tangential lighting vs perpendicular lighting
CHECK YOUR
EQUIPMENT
 Penlight
 Tongue depressor
 Ruler / tape measure
 Thermometer
 Sphygmomanometer
 Stethoscope
 Gloves
 Reflex hammer
 Tuning forks
MAKE THE PATIENT
COMFORTABLE
 Draping the patient
 Make your instructions
courteous and clear
 Be sensitive to the patient’s
feelings
CHOOSE THE SEQUENCE OF
THE EXAMINATION
 Maximize patient’s comfort
 Avoid unnecessary changes in position
 Enhance clinical efficacy
 Head – to – toe
CARDINAL TECHNIQUES OF
EXAMINATION
 Inspection
 Palpation
 Percussion
 auscultation
PHYSICAL EXAMINATION – A
BIRD’S EYE VIEW
 General Survey
 Vital signs

Always inspection palpation

 Skin
 Head, eyes, ears, nose, throat (HEENT)

percussion auscultation except in

 Neck

the abdominal examination

 Back
 Posterior thorax and lungs
 Breast, axillae, epitrochlear nodes
 Anterior thorax
 Cardiovascular system
 Abdomen
 Lower extremities
 Nervous System
 PRACTICE, PRACTICE, AND
MORE PRACTICE….
 General Data
 Source of history:
 Reliability: (how reliable in
percent??)
 Chief complaint:
 History of Present illness
 Medications
 Allergies
 Tobacco
 Alcohol and drug use
• Past history
• Childhood illnesses
• Adult illnesses:
Medical, surgical,
obstetric, psychiatric
• Family history
• Personal and social
history
• Review of systems