Medical History Taking and

Physical Examination
By: Dr.Muse M.(MD)
December 2022.
 History Taking - Your Objectives
• To elicit the pertinent facts from the patients
symptoms in relation to the illness;
• To clarify about clinical evaluation of a patient
• To derive a differential diagnoses,
• To elicit risk factors and significant co-morbid
pathologies
 CLINICAL EVALUATION
• Comprises of health history and physical
examination
• 80-90% of diagnosis is made by a good health
history and physical examination
• Guides next step or it is base for investigation
based evaluation
 ALWAYS
• GREAT THE PATIENT
• INTRODUCE YOURSELF TO THE PATIENT
• EXPLAIN TO HIM OR HER WHAT YOU ARE GOING
TO DO.
• MAINTAIN CONFIDENTIALITY
• ARRAGNGE THE ROOM
• GIVE YOUR UNDIVIDED ATTENTION
Components of Medical History Taking
• Identification of the patient
• Previous admission
• Chief complaint
• History of the present illness
• Past illness
• Personal and social history
• Family history
• Functional inquiry (review of system)
Identification
Name, age, race, sex, religion, occupation, marital status,
• date of admission, clerked date, ward and bed no.
• Name of informant (patient, relative).
• Source of referral
• Previous admission: duration and outcome of admission
Chief Compliant:
• The main season given by patient for seeking medical care and
the duration of the symptom.
• Can be one or more.
 History of Present Illness (HPI):
• Describe the course of the patient's illness, including when it
began, character of the symptoms, location where the symptoms
began; aggravating or alleviating factors;
• Preceding events or precipitating factor (when did you last feel
quite well ?)
• Pertinent positives and negatives statements regarding HPI
• Describe past illnesses and results past diagnostic testing.
• List all drugs with doses and frequencies that patients taking for
past illnesses
 Example: Questions to ask about Pain
• How, when did it start, how long did it last?
• How bad was it?
• Where was it felt?
• Did it radiate? Did it change, move?
• Did anything make it better or worse?
• What was the character (dull/sharp)?
• Was it constant or colicky?
• Any associated features?
 Example cont….
• Cough: Duration? dry or productive?, amount
per coffee arabica cup, color, odor, is there mixed
blood?, Is there associated chest pain, night
sweating, weight loss?
• Diarrhea: duration, frequency,
consistence(watery, blood mixed, bulk),
• Fever: intermittent?, relapsing?, is there
associated chills, rigor or headache?
Past Medical History:
• Past diseases, surgeries, hospitalizations; medical problems;
• History of diabetes, hypertension, peptic ulcer disease, asthma,
myocardial infarction, cancer.
Allergies to drugs: e.g Penicillin,
Family History:
• Medical problems in family, including the Asthma, coronary artery
disease, heart failure, HTN and cancer and diabetes.
• No. of sibling and health status of all family members
• If one of the parents are diseased, state the possible cause of death
Personal and Social History:
• Alcohol, smoking, khat chewing, drug usage.
• Average income and housing condition
• Marital status, employment situation.
• Level of education.
 Review of Systems (ROS)
o General: Weight gain or loss, loss of appetite,
fever, chills, fatigue, night sweats.
o Head: Headaches, dizziness, masses, seizures.
o Eyes: Visual changes, eye pain.
o Ears: Tinnitus, vertigo, hearing loss.
o Nose: Nose bleeds, discharge, sinus diseases.
o Mouth and Throat: Dental disease, hoarseness,
throat pain.
 Review of Systems cont…

 Cardiorespiratory: Cough, shortness of breath, sputum

(color), Chest pain, orthopnea, paroxysmal nocturnal
dyspnea; dyspnea on exertion, claudication, edema,
 Gastrointestinal: Dysphagia, abdominal pain, nausea,
vomiting, hematemesis, diarrhea, constipation, melena
(black tarry stools), hematochezia (bright red blood per
rectum).
 Genitourinary: Dysuria, frequency, hesitancy,
hematuria, discharge.
 Review of Systems cont…
• Endocrine: Polyuria, polydipsia, skin or hair
changes, heat intolerance.
• Musculoskeletal: Joint pain or swelling, arthritis,
myalgias.
• Skin and Lymphatic's: Easy bruising, Rashes, skin
discolorations. lymphadenopathy.
• Neuropsychiatric: Weakness, seizures, memory
changes, depression
 PHYSICAL EXAMINATION
“””ALWAYS”””
• STAND ON THE RIGHT SIDE
• WARM YOUR HANDS
• EXPLAIN THE PATIENT FOR WHAT YOU ARE
GOING TO DO.
• MAINTAIN CONFIDENTIALITY
• ARRAGNGE THE ROOM
 Physical Examination
General appearance:
• Note whether the patient appears ill, well, or malnourished.
Vital Signs:
• Temperature( site, time in day),
• heart rate( volume, regularity),
• Respiratory rate (pattern and depth of breath)
• blood pressure(supine, sitting and compare BP between arms)

HEENT
Head: Bruising, masses, ulcer
Eyes: Pupils equal round and react to light and accommodation; extra
ocular movements intact (EOMI), and visual fields.
scleral icterus, conjuctival color, ptosis
Funduscopy (papilledema, arteriovenous nicking, hemorrhages,
exudates)
 HEENT cont…
Ears: any discharge, tympanic membranes (dull, shiny,
intact, injected, bulging).
Nose: any bleeding, any discharge, sinus tenderness
Mouth and Throat: Mucus membrane color and
moisture; oral lesions, dentition, pharynx, tonsils.
 Lymphoglandular system
• Examine Lymph Nodes in Cervical, supraclavicular,
axillary, inguinal areas; size, texture, tenderness.
• Examine thyroid gland and testicles: size, texture,
tenderness
• Examine breast(females): each quadrant for mass,
tenderness, overlying skin changes, dimpling,
symmetry, nipple discharge
 Respiratory(chest) Examination
Inspection
• Note the shape of the chest and the way in
which it moves, including:
– Deformities or asymmetry
– Abnormal retraction of the interspaces during inspiration
– Impaired respiratory movement on one or both sides or a
unilateral lag (or delay) in movement.
PALPATION
• Identify tender areas. Carefully palpate any area where
pain has been reported or where lesions or bruises are
evident.
• Assess any observed abnormalities such as masses or
sinus tracts
• Examine position of trachea
• Test chest expansion
• Feel for tactile fremitus.
- Fremitus refers to the palpable vibrations of sound which
transmitted through the bronchopulmonary tree to the chest
wall when the patient speaks.
- Palpate and compare symmetric areas of the lungs to Identify
and locate any areas of increased, decreased, or absent
fremitus.
PERCUSSION
• Percussion helps to establish whether the underlying tissues
are air-filled, fluid-filled, or solid.
• When comparing two areas, use the same percussion
technique in both areas.
• Percuss or strike twice in each location.
• It is easier to detect differences in percussion notes by
comparing one area with another than by striking repetitively
in one place.
PERCUSSION cont…

• Identify the descent of the diaphragms, or

diaphragmatic excursion.

• With this technique you are identifying the boundary

between the resonant lung tissue and the duller
structures below the diaphragm.

• It determines the distance between the level of

dullness on full expiration and the level of dullness
on full inspiration, normally about 5 cm or 6 cm.
 AUSCULTATION
• It is the most important examining technique for
assessing air flow through the tracheobronchial
tree.
• Auscultation involves
(1) listening to the sounds generated by breathing,
(2) listening for any adventitious (added) sounds, and
(3) if abnormalities are suspected, listening to the
sounds of the patient’s spoken or whispered voice
as they are transmitted through the chest wall.
• Listen for the pitch, intensity, and duration of the
expiratory and inspiratory sounds.
Transmitted Voice Sounds
• If you hear abnormally located bronchovesicular or
bronchial breath sounds, continue on to assess
transmitted voice sounds.
• Ask the patient to say “ninety-nine.” Normally the
sounds transmitted through the chest wall are
muffled and indistinct.
– Louder, clearer voice sounds are called
bronchophony( shows abnormality)
• Ask the patient to say “ee.” You will normally hear a
muffled long E sound.
– When “ee” is heard as “ay,” an E-to-A change (egophony)
is present, as in lobar consolidation from pneumonia.
Thank you