Physical Exam & History Taking
Why we perform P/E & Health Hx
• Identify problem symptoms & abnormal
findings
• Linking findings to an underlying process of
pathology
• Establishing and testing a set of explanatory
hypotheses
Component of the health history
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Identifying Data or Initial Information
Chief complaint
Present illness
Past history
Family history
Personal and social history
Review of the system
Components of adult health history
• I- Initial information
1. date & time of history
2. identifying data & source of history or
referral
3. reliability; information should be
documented if relevant
( memory, trust, mood)
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• II-Chief complaint: the one or more symptoms
or concerns causing patient to seek help.
• Quote patient own words.
• E.g. “my stomach hurt me & I feel sick”
• E.g. “ I come for my regular check up”
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• III- present
illness: a complete &
clear description of problems that
patient seeking help
Characteristics of present illness
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Location. Where is it? Does it radiate?
Quality. What is it like?
Quantity. How bad is it?
Timing. When did it start? How long does it last?
How often does it come
• Setting in which it occurs including environment,
personal activities & others
• Remitting or exacerbating factors
• Associated manifestations
• Present illness should reveal pt. responses to
his symptoms & what effect the illness has
had on pt. life
• Medications, allergies, tobacco, alcohol should
also be noticed, …. risk factors.
• For patient with more than one symptom,
each symptom merits own paragraph and full
description.
• IV- past history includes
• Childhood illnesses; mumps, measles,…..
• Adulthood illnesses; Medical, surgical,
obstetric, psychiatric,
• Health maintenance(immunizations &
screening tests)
• V- family history
• Outlines age, health, & cause of death
of parents, siblings & grandparents
• Documents presence or absence of
specific illnesses in family e.g. HTN
• VI- personal & social history
• “Pt. personality, interest, source of
support, coping styles, strengths, fears.
• occupation, significant others, level of
education, source of stress, leisure's
activity, job Hx and concerns, ADL, &
others.
• VII- Review of body systems
• Document presence or absence of common
symptoms related to each major body system
• It is part of subjective data
e.g.. Head, headache, head injury
– Eyes: visions, glasses, contact lenses, pain,
redness, excessive tearing, double or blurred
vision
– Ears: hearing, tinnitus, infection, discharge
Physical Exam Approach
• There are two approaches of P/E
• 1. comprehensive P/E conducted for most new
pts being admitted to hospital
• 2. problem oriented or focused: segments of
examination
• P/E begin with general survey & V/S
• General survey; height, weight, gait,
groom,…..others.
Physical Assessment Methods
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Inspection
Palpation
Percussion
Auscultation
Inspection
• Assessment
process during
which the nurse
observes the client
Inspection
• Initial contact and ongoing
• General appearance, body language
• Examine: color, size, shape, position, symmetry
(compare like areas)
• Systematic unhurried approach
• Expose part, respect privacy
• Know “normals”
• Observe “normals/abnormals”
Palpation
• The use of the hands and the sense of touch
to gather data or tactile pressure from the
palmar fingers or finger pads to assess areas
of skin elevations , depression and others.
Palpation
• Detects texture, temp, movement,
pain, moisture
• Short fingernails, warm hands
• Gentle approach
Percussion
• Tapping of various
body organs and
structures to
produce vibration
and sound.
Auscultation
• The act of
listening to
sounds within the
body to evaluate
the condition of
body organs
• (stethoscope)
Equipment
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Stethoscope
Pen light
Blood Pressure Cuff
Thermometer
Watch with second hand
Preparing for Physical Examination
• Reflect on your approach to the patient
identify self, be calm, organized, competent
• Adjust the lightening and the environment
• Make the patient comfortable; Minimize how
often you ask the patient to change position.
• Check your equipment
• Choose the sequence of examination
Subjective and Objective data
Subjective data
Objective data
What the patient tell you What you detect from
the physical examination
• The history
• All the physical
• Chief complain
examination findings
• Review of the system
are objective data
Recoding findings
• Purposes
• 1. organize information from Hx &P/E
• 2.communicate patients clinical issues to all
members of health team
• There is a special format which document
findings
• Information should be taken as soon as
possible
• The order of writing should be consistence
• The degree of details should be pertinent to
the subject or problem but not redundant
Principles of Documentation
• Timing: as soon as
possible
• Confidentiality
• Signature
• Accuracy
• Sequence
• Appropriateness
• Completeness
• Standard
Terminology
• Legal Awareness
Interviewing
• Purposes of Interview
• 1. to establish a trusting & supportive
relationship
• 2. to gather information
• 3. to offer information
• The process of interviewing pt requires a
highly refined sensitivity to pt feelings &
behavioral cues
• The interviewing process is much fluid &
demands effective communication &
relational skills
• It requires not only knowledge of data you
need to obtain but also the ability elicit
accurate information & interpersonal skills
that allow you to respond to pt feelings &
concerns
The Approach of Interview
• I. getting ready
• A. taking time for self reflection
Aware of our own values, assumptions, biases
Being respectful and open for differences
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B. reviewing the chart
C. setting goals for the interview
D. reviewing your clinical behavior & appearance
E. adjusting the environment
F. taking notes
• II. The sequence of interview
• 1. greeting pt & establish rapport
• 2. Establishing an agenda
there is specific goals in mind for interview
use time effectively
obtain C/C
Begin with open ended questions
“ how can I help you “
“ what concerns bring you here today”
• 3. inviting pt story
use verbal & nonverbal cues
“nodding head” “saying ah huh” “go on”
“tell me more” “ what else”
Listen to pt without interruption
• 4.Identifying and responding to patients
emotional cues
• 5. Expanding & clarifying pts story
• Guide pt into elaborating areas of history
• Try to clarify attributes of each symptom; OLD
CARTS (Onset, Location, Duration, Character,
Aggravating/Alleviating factors, Radiation,Timing,
Severity)
• or OPQRST; Onset, Palliating factors/ provoking
factors, Quality, Radiation, Severity/ Site, Timing
• Use language that is understandable& appropriate to
pt
• Try to use pts words and avoid technical ones
• 6. Generating and testing diagnostic hypotheses
• Symptoms- diagnoses?
• Yes/no ROS
• 7.Creating a shared understanding of the
problem
• We should ask pt. several questions about his
perception of illness
• It includes pt. thoughts or ideas about nature& cause
of problem
• Pt. feelings including fears or concerns about the
problem
• Pts. Expectations of health care
• The effect of problem on his life, function & others
• Example (about pain)
• Nurse; has anything like this happen to you or
your family before?
• Pt; I was worried that I might have
appendicitis. My uncle died of a ruptured
appendix
• 8. negotiate a plan
• It gives basis for planning further evaluation
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P/E, lab test, consultation) & negotiating a treating
plan
• 9. planning for follow up and closing
• Let pt know the end of interview is approaching to
allow time for the patient to ask questions
• Make sure pt understand the mutual plans you have
developed
• Example
• “we need to stop now. Do you have any
questions about what we covered”
• As you close review future evaluation,
treatment, & follow up.
III-building a therapeutic relationship; The
techniques of skilled interviewing
• 1. building the relationship; by active listening
• 2. using guided questions;
a. moving from open ended to focused questions
b. using questioning that elicit a grade response
c. asking a series of questions
d. offering multiple choices for answers
e. clarifying what the patient means
f. encouraging with continuers
g. using echoing
III-building a therapeutic relationship
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3.nonverbal communication
4.empathic responses (acknowledge pt feelings)
5.Validation (acceptance of feeling)
6. reassurance
7.partnering; to make explicit your desire to work
with them in ongoing way
8. summarization
9.transition
10. empowering patient;
Pt should be confident by himself
IV- Adapting your interview to specific
situations
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The silent patient
The confused patient
The talkative patient
The crying patient
The angry and disruptive patient
Patients with low literacy
Patients with impaired vision/ hearing/
Patients with limited intelligence
V- Sensitive topics that call for specific
approach
• Guidelines for broaching sensitive topics (
abuse of alcohol or drugs, sexual practices,
death, violence, ….etc)
• 1. be non judgmental
• 2. explain why you need to know certain
information
• 3.find opening questions for sensitive topics
and learn the specific kinds of data needed for
your assessment
• Examples;
• “what do you like to drink”
• “have you ever had a drinking problem of
alcohol”
• “have you ever used any drugs other than
those required for medical reasons”
• “when was the last use”
• “how often substance use”
General Survey
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1. Apparent state of health
2. Level of consciousness
3. Signs of distress
4. Height and build
5. Weight
6. Skin color and obvious lesions
7. Dress, grooming, and personal hygiene
8. Facial expressions
9. Odors of body and breath
10. Posture, gait, and motor activity