History and Physical Examination Mike Clark, M.D.

Patient Presents The patient comes to the physician’s office with a problem. The clinician listens to the patient’s problem (symptoms). The patient may also show visually or audibly signs of the problem. From this the clinician must figure out what the problem is (diagnosis). In order to do this the clinician must first perform a history and physical examination. It is as a result of the history and physical examination that certain laboratory tests are decided upon.

How to Take a Patient History 1.Chief Complaint (what is the reason the patient came into the office – write down preferably in the patient’s own words) 2.History of Present Illness – This is where a more complete description of why the patient presented. It will include everything historically (questioning of patient) that can pertain to the chief complaint. Example – John is a 27 year old male who presents with

3.Past Medical History – ask questions to obtain a good past medical history (medical illnesses, surgeries, medications being taken, blood transfusions, allergies) 4.Family History – ask questions about history of diseases that could be genetic (diabetes, cancers, heart disease, mental disorders, autoimmune disorders) 5.Social History - ask questions related to living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets

6.Review of Systems - generally presented in a questionnaire to be sure every system historically has been investigated. (See example of form)

Physical Examination In a physical examination – all that can be done is Visualization – observe the patient Palpation – feel areas of the patient Percussion – a thumping action to identify organ borders Auscultation – listen to patient sounds

Physical Examination 1.Vital Signs and Biometrics ( Height, Weight, Temperature, Blood Pressure, Pulse, Respiratory Rate) Note: How much detail you go into during the physical exam depends on the specialty. 2.HEENT – head, ears, eyes, nose and throat 3.Lungs – checking for breath sounds – expansion of the chest and other findings 4.Heart- sounds, heaves, thrusts, PMI 5.Abdomen – intestinal sounds, pain, lumps and other findings 6.Extremities – pulses and other findings 7.Neurological – reflexes, cranial nerves and other findings 8.Gynecologic 9.Psychiatric

Impression / Differential Diagnosis As a result of the findings in the patient history combined with the findings in the physical examination – the clinician compiles a list of possibilities of what he/she thinks the condition that brought the patient in may be. Additionally, the clinician lists all the conditions patient is already known to have.

Plan The plan is the action to be taken. Part of the plan in involves the R/O process (Rule Out). This is the process where the clinician orders certain directed laboratory tests in order to confirm or rule out disease possibilities on his/her differential diagnosis list. The other plan involves treatment for conditions that have been confirmed.