MAKING A MEDICAL DIAGNOSIS
Bates, Barbara, A Guide to Physical Examination and History Taking,
J.B. Lippincott Company, Philadelphia, PA, 1995.
A person experiencing serious symptoms usually seeks professional help and thereby
becomes a patient. The clinician, whether a nurse, physician, or emergency medical
technician, must determine the need for medical care on the basis of observation and
assessment of the patient’s symptoms and signs. This is the process of diagnosis: the
identification of a pathological process by its characteristic symptoms and signs.
Diagnosis is a lot like assembling a jigsaw puzzle. The more pieces (clues) available, the
more complete the picture will be. The process of diagnosis is one of deduction and
follows an orderly sequence of steps:
1. Obtain the patient’s medical history. The medical history is a concise summary
of the present illness, past medical disorders, the health of the patient’s family, the
psychosocial history, and general factors that may affect the function of body
systems. The examiner gains information about the person’s concerns by asking
specific questions and using good listening skills. Physical assessment begins
here, and this is the time for unspoken questions such as, “Is this person moving,
speaking, and thinking normally?” The answers will later be integrated with the
results of more-precise observations.
2. Perform a physical examination. The physical examination is a basic but vital
part of the diagnostic process. The common techniques used in physical
examination include inspection (vision), palpation (touch), percussion (tapping
and listening), and auscultation (listening). Certain vital functions are also
checked.
3. If necessary, perform diagnostic procedures. The physical examination alone may
not provide enough information to permit a precise diagnosis. Diagnostic
procedures can then be used to focus on abnormalities revealed by the physical
examination. For example, if the chief complaint is knee pain after a fall and the
physical examination reveals swelling and localized, acute pain on palpation, the
preliminary diagnosis may be a torn cartilage. An X-ray or MRI scan or both may
be performed to ensure that there are no torn ligaments. With the information the
diagnostic procedure provides, the final diagnosis can be made with reasonable
confidence. Diagnostic procedures thus extend, rather than replace, the physical
examination.
COMPREHENSIVE HISTORY
Patient Name:
Date of History:
Identifying Data: age, sex, race, place of birth, marital status, occupation, religion.
Source of Referral: if any, and the purpose of it.
Source of History: such as the patient, a relative, a friend, the patient’s medical
record, or a referral letter.
Reliability: if relevant. (of patient interview, often based on level of coherence)
Chief Complaint: when possible, in the patient’s own words.
Present Illness: A clear, chronological account of the problems for which the patient is
seeking care. Should include the onset of the problem, the setting in which it developed,
its symptoms, and any treatments. Principal symptoms should be described in terms of
1) location, 2) quality, 3) quantity or severity, 4) timing (i.e., onset, duration, and
frequency), 5) the setting in which they occur, 6) factors that have aggravated or relieved
them, and 7) associated manifestations. Also significant negatives (the absence of certain
symptoms that will aid in a differential diagnosis).
A present illness should also include patients’ responses to their own symptoms and
incapacities. What does the patient think has caused the problem? What are the
underlying worries that have led to seeking professional attention? (“I think I may have
appendicitis.”) And why is that a worry? (“My Uncle Charlie died of a ruptured
appendix.”) Further, what effects has the illness had on the patient’s life? This question
is especially important in understanding a patient with chronic illness. “What can’t you
do now that you could do before? How has the backache, shortness of breath, or
whatever, affected your ability to work?...your life at home?...your social
activities?...your role as a parent?...your role as a husband, or wife?...the way you feel
about yourself as a man or woman?”
PAST HISTORY
General State of Health: as the patient perceives it.
Childhood Illnesses: such as measles, rubella, mumps, whooping cough, chickenpox,
rheumatic fever, scarlet fever, polio.
Adult Illnesses
Psychiatric Illnesses
Accidents and Injuries
Operations
Hospitalizations not already described
Current Health Status
Current Medications
Allergies
Tobacco, Alcohol, Drugs, and Related Substances: including type, amount, duration of
use, e.g., cigarettes, a pack a day for 12 years.
Diet: including usual daily intake and any dietary restrictions or supplements. Ask about
coffee, tea, cola drinks, and other caffeine-containing beverages.
Screening Tests: appropriate to the patient, such as TB tests, Pap smears, mammograms,
stools for occult blood, and cholesterol tests, together with the results and the dates they
were last performed.
Immunizations: such as tetanus, pertussis, diphtheria, polio, measles, rubella, mumps,
influenza, hepatitis B, pneumoccal vaccine.
Sleep Patterns: including times that the person goes to bed and awakens, daytime naps,
and any difficulties in falling asleep or staying asleep.
Exercise and Leisure Activities:
Environmental Hazards: including those in the home school, and workplace
Use of Safety Measures: such as seat belts, smoke detectors, and other devices related to
specific hazards.
FAMILY HISTORY
The age and health, or age and cause of death, of each immediate family member.
The occurrence within the family of any of the following conditions: diabetes, heart
disease, hypercholesterolemia, high blood pressure, stroke, kidney disease, tuberculosis,
cancer, arthritis, anemia, allergies, asthma, headaches, epilepsy, mental illness,
alcoholism, drug addiction, and symptoms like those of the patient.
PSYCHOSOCIAL HISTORY
Captures important and relevant information about the patient as a person.
Home Situation and Significant Others
Daily Life
Important Experiences: including upbringing, schooling, military service, job history,
financial situation, marriage, recreation, retirement.
Religious Beliefs: relevant to perceptions of health, illness, and treatment.
The Patient’s Outlook: on the present and on the future
REVIEW OF SYSTEMS
General: Usual weight, recent weight change, any clothes that fit tighter or looser than
before. Weakness, fatigue, fever.
Skin: Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails
Head: Headache, head injury
Eyes: Vision, glasses or contact lenses, last eye examination, pain, redness, excessive
tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts
Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased,
used of hearing aids
Nose & Sinuses: Frequent colds; nasal stuffiness, discharge, or itching; hay fever,
nosebleeds, sinus trouble
Mouth & Throat: Condition of teeth and gums, bleeding gums, dentures, if any, and
how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats,
hoarseness
Neck: Lumps, “swollen glands,” goiter, pain or stiffness in the neck
Breasts: Lumps, pain or discomfort, nipple discharge, self-examination
Respiratory: Cough, sputum (color, quantity), hemoptysis, wheezing, asthma,
bronchitis, emphysema, pneumonia, tuberculosis, pleurisy; last chest x-ray film
Cardiac: Heart trouble, high blood pressure, rheumatic fever, heart murmurs; chest pain
or discomfort, palpitations; dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema;
past electrocardiogram or other heart test results
Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, vomiting,
regurgitation, vomiting of blood, indigestion. Frequency of bowel movements, color and
size of stools, change in bowel habits, rectal bleeding or black tarry stools, hemorrhoids,
constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing
gas. Jaundice, liver or gallbladder trouble, hepatitis
Urinary: Frequency of urination, polyuria, nocturia, burning or pain on urination,
hematuria, urgency, reduced caliber or force of the urinary stream, hesitancy, dribbling,
incontinence; urinary infections, stones
Genital
Male: Hernias, discharge from or sores on the penis, testicular pain or masses, history of
sexually transmitted diseases and their treatments. Sexual preference, interest, function,
satisfaction, and problems
Female: Age at menarche; regularity, frequency, and duration of periods; amount of
bleeding, bleeding between periods or after intercourse, last menstrual period;
dysmenorrheal, premenstrual tension; age at menopause, menopausal symptoms,
postmenopausal bleeding. Discharge, itching, sores, lumps, sexually transmitted diseases
and their treatments. Number of pregnancies, number of deliveries, number of abortions
(spontaneous and induced); complications of pregnancy; birth control methods. Sexual
preference, interest, function, satisfaction; any problems, including dysparenia
Peripheral Vascular: Intermittent claudication, leg cramps, varicose veins, past clots in
the veins
Musculoskeletal: Muscle or joint pains, stiffness, arthritis, gout, backache. If present,
describe location and symptoms (e.g., swelling, redness, pain, tenderness, stiffness,
weakness, limitation of motion or activity).
Neurologic: Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of
sensation, tingling or “pins and needles,” tremors or other involuntary movements
Hematologic: Anemia, easy bruising or bleeding, past transfusions and any reactions to
them
Endocrine: Thyroid trouble, heat or cold intolerance, excessive sweating; diabetes,
excessive thirst or hunger, polyuria
Psychiatric: Nervousness, tension, mood including depression; memory
PHYSICAL EXAMINATION

Inspection is careful observation. A general inspection involves examining body
proportions, posture, and patterns of movements. Local inspection is the
examination of sites or regions of suspected disease. Of the four components of
the physical exam, inspection is often the most important because it provides the
largest amount of useful information. Many diagnostic conclusions can be made
on the basis of inspection alone; most skin conditions, for example, are identified
in this way. A number of endocrine problems and inherited metabolic disorders
can produce subtle changes in body proportions that can be detected by the
trained eye. Inspection can allow for identification of any deformities,
asymmetry, or inflammation.

In palpation, the clinician uses hands and fingers to feel the body. This
procedure provides information on skin texture and temperature, the presence of
abnormal tissue masses, the pattern of the pulse, and the location of tender spots.
Once again, the procedure relies on an understanding of normal anatomy. In one
spot, a small, soft, lumpy mass is a salivary gland; in another location it could be
a tumor. A tender spot is important in diagnosis only if the observer knows what
organs lie beneath it. Palpation can help determine the borders of the heart, as
well as the presence of an enlarged liver, spleen, or kidney.

Percussion is tapping with the fingers or hand to obtain information about the
densities of underlying tissues. Percussion helps to determine whether the
underlying tissues are air-filled, fluid-filled, or solid. For example, when tapped,
the chest normally produces a hollow sound, because the lungs are filled with air.
That sound changes in pneumonia, when the lungs contain large amounts of fluid.
To get the clearest chest percussion, the fingers must of course be placed in the
right spots. Percussion techniques are also use to determine the borders of various
organs (such as the spleen and liver). Flat (most dense), dull, resonant,
hyperresonant, and tympanic (least dense) are the percussion “notes”. An
example location (if you would like to test these sounds) for “flatness” is the
thigh; dullness—the liver; resonance—the normal lung; hyperresonance—none
normally (but present in cases of emphysema and pneumothorax); and tympany—
gastric air bubble or puffed-out cheek. In a physical examination, the clinician
may percuss the abdomen lightly in all four quadrants to assess the distribution of
tympany and dullness. Tympany usually predominates because of gas in the
gastrointestinal tract, but scattered areas of dullness due to fluid and feces there
are also typical. Large dull area in the abdomen may indication the presence of an
underlying mass or an enlarged organ, and this observation would help guide with
a subsequent palpation.

Auscultation is listening to body sounds, typically using a stethoscope. This
technique is particularly useful for checking the condition of the lungs during
breathing. The wheezing sound heard in people with asthma is caused by
constriction of the airways, and pneumonia produces a gurgling sound, indicating
that fluid has accumulated in the lungs. Auscultation is also important in
diagnosing heart conditions. Many cardiac problems affect the sound of the
heartbeat or produce abnormal swirling sounds during blood flow.
Every examination also includes measurements of certain vital body functions, including
body temperature, blood pressure, respiratory rate and heart (pulse) rate. The results,
called vital signs, are recorded on the patient’s chart. As we noted earlier, each of these
values can vary over a normal range that differs according to the age, gender, and general
condition of the individual. The table below indicates the representative ranges for vital
signs in infants children and adults.
Normal Range of Values for Resting
Vital Sign
Infant
(3 months)
90/50
Blood Pressure
(mm/hg)
30-50
Respiratory Rate
(per minute)
70-170
Pulse Rate
(per minute)
Individuals by Age
Child
(10 years)
125/60
Group
Adult
95/60 to 140/90
18-30
8-18
70-110
50-95
DIAGNOSTIC PROCEDURES
There are two general categories of diagnostic procedures:
1.
Tests performed on the individual, generally within a hospital facility.
A. Visualize internal structures (endoscopy, X-rays, scanning procedures,
ultrasonography, mammography)
B. Monitor physiological processes (EEG, ECG, PET, RAI, pulmonary
function tests)
C. Assess the patient’s homeostatic responses (stress testing, skin tests)
2.
Tests performed in a clinical laboratory on tissue samples, body fluids, or
other materials collected from the patient.