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

• Stethoscope

• Sphygmomanometer (BP cuff)

• Tape measure

• Gloves

• Emesis basin

• Thermometer

• Cotton balls / antiseptic solution

• Knife handle / blade

• Hemostat

• Curved scissors (Metzenbaum)

• Sponge forceps

• Tissue forceps

• Suture scissors

• Needle holder

• Hypodermic needle / syringe

• Mosquito forceps

• Towel clips

• Towels

• Gauze strips

• Drape or sheet