History taking and Physical
Examination
Ayelech A. (MD)
(internist ,nephrology fellow)
1
Outline
• Objective
• Introduction
• History taking
• Physical examination
• Summary
2
Objective
• At the end of this lesson you should
-Mention component of history taking and
physical examination
-Be able to take history
3
Introduction
• History is what the patient tells you
• Physical examination is what you detect on the
patient
• Purpose of medical practice is to relief suffering
• To achieve the above goal we first need to
diagnose the patient’s problem using history and
physical examination
• In more than 70% of the case proper history and
physical examination can lead to correct diagnosis
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History taking
• Greet the patient and ask for his/her
permission before starting history taking
• History taking has its own format or steps
which is presented as follows
• Date and time
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1)Identification of the patient
• Name
• Age
• Sex
• Occupation
• Religion
6
2)Previous admission
• Includes previous hospital admission
• Ask
-cause of hospital admission
-time and place(hospital) of admission
-course of hospitalization
-outcome of hospitalization
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3)Chief compliant
• Is the main compliant that bring the patient to
health institution
• A patient may have one or more chief
complaint
• Duration of chief complaint should be asked
• E.g. cough of 2 weeks duration
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4)History of present illness
• Is the part where you describe the chief compliant
• Symptoms should be put chronologically
• Characterize each symptom like
-quality of symptom
-quantity or severity of symptom
-timing, mode of onset, duration and frequency
-location
-associated symptom
-aggravating and remitting factor
-setting in which symptom occurs 9
Cont.…d
• Negative- positive symptom
• Mode of admission to hospital should be
mentioned.
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5)Past illness
• Childhood illness like measles, mumps and
chicken pox
• history of trauma
• Previous medical or surgical
• Any history of psychiatric problem
11
6)Personal and social history
• Early development-date and place of birth,
Breast fed or not
• Education
• Social activities
• Work records
• Habits
• Marital status
• Living condition
12
7)Family history
• Parents → age , alive or not, if died cause of
death, if alive current health condition
• Siblings → age , health condition
• Family disease → diabetic mellites , asthma
13
8)Allergy and Medication history
• Any drug the patient taking → name , dose,
frequency, route of administration, duration
of treatment
• Any known allergen
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9)Functional inquiry/System review
• Documents presence or absence of common symptom related to
each body system
• HEENT
-Head: headache, trauma
-Ears: loss of hearing, discharge , earache,
tinnitus , vertigo
-Eyes: eye pain, lacrimation ,photophobia ,loss
of vision , discharge , blurring of vision
-Nose: epistaxis, discharge
-Mouth and Throat: sore throat, dental pain,
gum bleeding
15
Cont’d…
• Glands
-neck swelling, breast lump ,nipple discharge
• Respiratory
-cough, chest pain, shortness of breath,
wheeze, hemoptysis
• Cardiovascular
-dyspnea, orthopnea , paroxysmal nocturnal
dyspnea, retrosternal chest pain, palpitation
16
Cont’d…
• Gastrointestinal system
-dysphagia, odynophagia, heartburn,
vomiting, diarrhea,
loss of appetite , abdominal cramp, abdominal
swelling ,jaundice , color of stool
• Genitourinary system
-frequency , dysuria , hematuria, urgency,
dribbling, flank or suprapubic pain , menstrual
history
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• Integumentary system
-Hair: hair loss, color change
-Skin: skin rash, moisture , pigmentary changes
-Nail: color of nail, deformity
• Musculoskeletal system
-Trauma , limping , muscle weakness, joint pain
or swelling
• Nervous system
-loss of consciousness , speech difficulty , diplopia,
failure to use extremity , abnormal body movement
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Physical Examination
• General appearance
-Conscious or not
-Acutely or chronically sick looking
*Acute → pain , cardiorespiratory distress,
comatose
*Chronic →wasted , prominent zygoma,
depressed eye ball, pallor
-Comfortable lying on the bed
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• Vital sign
-Pulse rate → rate , rhythm , volume , site
where you check the pulse
-Respiratory rate → rate , pattern of breathing
-Blood pressure → supine an sitting, site
-Temperature → site
• Interpretation of vital sign is important
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Con’t…d
• HEENT
• Lymphoglandular
• Respiratory
• Cardiovascular system
• Gastrointestinal system
• Genitourinary system
• Integumentary system
• Musculoskeletal system
• Nervous system
21
summary
• Subjective-summarize history in short
• Objective-document major physical finding
including persistent negative symptom
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THANKS!
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