History and Physical Exam
HST 2
Rationale
• Health care workers are on the front
line of fighting the spread of infectious
disease. One of the most important
aspects of their job is accurately
diagnosing a disease by collecting the
right types of information from the
patient. It is necessary to obtain an
accurate patient history and physical
examination.
Objectives
• Student expectations:
• Record a simple patient history
• Perform a patient exam, focusing on pulse,
temperature, and respiration.
• Diagnose illness by matching observed
symptoms with diseases, using a checklist.
• Suggest appropriate course of treatment.
• Describe symptoms and risk factors of
various infectious diseases.
Key Points
• Information gathered while performing
a history and physical on a patient
helps the physician determine:
• Patient’s level of health
• Need for additional testing or
examinations
• Tentative diagnosis
• Preventive measures needed
• Type of treatment
Length and Detail
• At times, the history may need to be in
great detail.
• For example, when a patient goes to a
specialist, the patient may be asked to
fill out a very lengthy form about any
problems in the past that indicate a
pattern.
• But, many times a simple history is all
that is needed to give the physician a
good idea about what is going on with
the patient.
• This is the best way to treat it, such as
a patient seeing a doctor for a sore
throat or broken arm, for example.
Common Components of H&P
• Chief complaint (CC) – a brief
statement made by the patient
describing the nature of the illness
(signs and symptoms) and the duration
of the symptoms, i.e. why the patient
came to see the physician.
• History of present illness (HPI) – detail
each symptom and look at the order of
the symptoms to occur and the length
of each. Example: when did it start,
describe the intensity, what makes it
worse or better, what relieves it, etc.
• Past History (PH) – all prior illnesses
the patient has had and the date.
• Childhood diseases
• Surgeries
• Hospital Admissions
• Serious injuries and disabilities
• Immunization record
• Allergies – all kinds, including any drug
reactions they may have had.
• For women only: number of
pregnancies, number of live births,
date of last menstrual cycle.
• Family History (FH) – the summary of
the health status and age of immediate
relatives (parents, siblings,
grandparents, children); if deceased,
the date, age of death, and cause.
• Hereditary diseases, such as cancer,
diabetes, heart disease, kidney
problems, mental conditions, infectious
diseases.
• Social and Occupational history (SH) –
• Information related to the type of job,
where the patient lives, recent travels,
occupational exposures, personal
habits and lifestyle:
• Use of tobacco, alcohol, drugs, coffee
• Diet, sleep, exercise, hobbies
• Marital history, children, home life,
occupation, religious convictions
• Resources and support
Physical Exam
• Usually performed by a physician.
• Part may be performed by a nurse,
therapist, PA, or other person.
• Types:
• Inspection – visual observations of the
body. Check for rashes, scars,
bruises, signs of trauma, deformities,
swelling.
• Many times, for inspection, instruments
are used for getting a better look, such
as an otoscope or a tongue blade.
• Palpation – by applying the tips of the
fingers, the whole hand, placing both
hands to a body part to feel for
abnormalities and noting any pain or
tenderness.
• Percussion – done by tapping the body
lightly, but sharply, with the fingers
when looking for the presence of pus,
fluid or air / gas in a cavity.
• Percussion hammer can be used when
checking the reflexes of a patient.
• Auscultation – the process of listening
to sounds produced internally.
Generally, a stethoscope is used.
Examples: listening to heart, lungs,
abdomen.
• Mensuration – the process of
measuring. Includes TPR, BP, Height
and Weight.
• Diagnostic Testing – testing to give the
physician a better look at what is going
on inside, most likely done after the
other parts of the exam.
• Examples include lab work, X-rays, or
more invasive procedures such as a
heart cath.
Preparing the patient for the
exam
• Patients are usually asked to undress
and put on a patient gown.
• Always drape the patients so that they
are covered except for the area to be
examined.
Common examination
positions:
• Horizontal recumbent (supine) –
the patient lies flat on back, with or
without a head pillow; legs
extended, arms across chest or at
sides.
• Prone – the patient lies facedown, legs
extended, face turned to one side and
arms above head or along side.
• Dorsal recumbent – the patient lies on
back, knees flexed, soles of feet flat on
bed.
• Knee-chest – the patient is on the
knees with chest resting on the
bed. The thighs are straight up
and down; the lower legs are flat
on the bed. The face is turned to
one side.
• Sim’s (lateral) – the patient lies on the
left side with the left arm and shoulder
front-side down on the bed. The right
arm is flexed comfortably. The right
leg is flexed against the abdomen; the
left knee is slightly flexed.
• Fowler’s – the back rests against the
bed, which is adjusted to a sitting
position. the bed section is raised
under the knees. A pillow is placed
between the patient’s feet and the foot
of the bed.
• Lithotomy – the patient lies on their
back. The knees are separated
and flexed. Sometimes, the feet
are placed in stirrups.
• Anatomic position (vertical) – the
patient stands upright with feet
together and palms forward.
• Dangling (sitting) – patient sits upright
on the side of the bed, facing the
doctor. Feet are resting on a stool or
dangling. This is the most common
position for exam, depending on their
chief complaint.
Equipment
• The equipment needed for examination
will depend upon the type of exam.
Some commonly used instruments:
• Tongue depressor
• Otoscope
• Nasal speculum
• Percussion hammer
• Opthalmoscope
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Stethoscope
Sphygmomanometer (BP cuff)
Tape measure
Gloves
Emesis basin
Thermometer
Cotton balls / antiseptic solution
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Knife handle / blade
Hemostat
Curved scissors (Metzenbaum)
Sponge forceps
Tissue forceps
Suture scissors
Needle holder
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Hypodermic needle / syringe
Mosquito forceps
Towel clips
Towels
Gauze strips
Drape or sheet