Medical Hstory and Physical Examination- Rapid Review

1. Medical History and Physical
Examination Rapid Review

2. Components of Medical History
2
 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)

3. Identifying Data (ID)
3
Name or initials
Date of birth
Medical record number

4. Chief Complaint (CC)
4
 One-liner--why patient here--use patient's own
words
 How to write--patient’s age, occupation or sex,
problem & duration

5. History of Present Illness (HPI)
5
Story of patient’s chief complaint (CC)
Story of any active/significant illnesses patient as
which impact on HPI

6. History of Present Illness (HPI)
6
Story of CC:
logical
complete
chronological

7. History of Present Illness (HPI)
7
Story of CC (How To Ask):
start with open-ended questions
fill in with focused questions

8. History of Present Illness (HPI)
8
Story of CC
Describe symptoms in terms of:
– location
– quality
– quantity (severity)
– timing
– setting
– aggravating and/or alleviating factors
– associated manifestations

9. History of Present Illness (HPI)
9
Story of CC
document:
– prior medical Dx/Rx
– significant positives or negatives

10. History of Present Illness (HPI)
10
Story of CC
Document patient’s understanding of his/her illness:
– patient’s fears and concerns
– impact of illness/treatment on patient, family

11. History of Present Illness (HPI)
11
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

12. Past Medical History (PMH)
12
Childhood illnesses
Immunizations
Adult illnesses
Psychiatric illnesses or Hospitalizations
Operations
Injuries/accidents
Obstetric history
Transfusions

13. Adult Illnesses
13
Dx & how made
Rx
Response & sequelae

14. Operations
14
Why
Kind
When & sequelae

15. Obstetric History
15
Number times pregnant
Number live births
Number abortions (spontaneous/induced)

16. Transfusions
16
Where
When
Why
Reactions/complications

17. Current Health Status (CHS)
17
Current medications--name, dose, reason, SE
Allergies/drug reactions
Health screening
Diet/sleep/exercise
Habits--tobacco, alcohol, elicit
Alternative Therapies

18. Psycho-Social History (PSH)
18
Marital status
Living conditions
Employment
Sexual history
Significant life events
Mental status

19. Family History (FH)
19
Mother/father/siblings/children
• age--health (if dead, why)
Significant illnesses that run in family

20. Review of Systems (ROS)
20
Characterize patient's overall health status
Review systems/symptoms from head to toe

21. Physical Diagnosis
21
• 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?

22. The Four Cardinal Principles of
Physical Examination:
22
• 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?)

23. Maintain a “watchful eye” during the
medical interview
23
• General Survey--Note:
• Level of Consciousness
• Apparent State of Health---General appearance--
Age Appropriate?
• State of Nutrition--Wasting?,…..
• Body Habitus

24. Watchful eye---
24
• 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

25. Watchful eye and Ear-----
25
• Speech
• Facial Expressions…fear?/ stoic?
• Appropriate facial responses to communication?

26. Signs of Distress?
26
• Address early on-----Note posture, Labored
Breathing? Sweating? Trembling….Chills?
Wincing?….Pain

27. Preparing For The Exam
27
• Lighting
• Equipment
• Universal Precautions
• Patient Comfort

28. The Science of Physical Examination
28
• 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

29. BLOOD PRESSURE
29

30. Arterial pressure
30
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

31. Arterial pressure (2)
31
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

32. What’s The Difference???-better yet What
does it all mean?
32
• 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

33. Techniques of Exam--BP
33
• 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

34. Techniques of Exam-BP
34
• How to Assess?
• Normal Values & Changes from the
Norm?…Adult, Infant, Pregnancy, Geriatric...
• Clinical Significance?…Elevation-Hypertensive,
…Low-Hypotensive…Orthostatic Changes

35. Techniques of Exam--Pulse
35
• Pulse= denotes the heart rate & rhythm,
condition of the arterial walls
• How to Assess?
• What do my readings tell me? Rapid?
Slow?

36. Vital Signs… Respiratory Rate
36
• 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

37. Vital Signs
37
• Clinical significance:
• Temperature
• Weight
• Height

38. How do I write it all down?
38
• 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)

39. 39
THE END
See next slide for links to tools
and resources for further study.

40. Sources and Further Study:
40
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.)