1.1.

1
2 June
2014

History Taking and Clinical Decision Making

Alfredo Guzman, M.D.
The adrenaline and stress of an adventure are better than a thousand peaceful days.
Paulo Coelho

Paulo Coelho
TOPIC OUTLINE
I.
II.
III.
IV.
V.
VI.
VII.

VIII.
IX.
X.
XI.

The Value of History Taking

First Impressions
Establishing the Patient Relationship
Tips for Effective History Taking
The History & PE: Comprehensive or Focused?
Components of the Health History
Elements of the Comprehensive Health Hx
(Guidelines for Hx Taking & PE)
A. General Data
B. Chief Complaint (CC)
C. History of Present Illness (HPI)
D. Past Medical History
E. Family History
F. Personal/ Social History
Review of Systems
Special Challenges and Common Pitfalls
Physical Exam (Highlights)
Clinical Decision Making

THE VALUE OF HISTORY TAKING

Directs the focus of the physical exam

Often the basis for differential diagnosis (differential diagnosis are
done during Hx taking)
Keys
o Trust (respect, dress appropriately, etc.)
o Right questions (open/close ended Qs)
o Interpreting responses
o Knowing what to do next
Care begins simultaneously

- the Hx,from CC through ROS

Objective Data
- What you detect during the examination
- All PE findings
Pain most common sx
THE HISTORY & PE: COMPREHENSIVE OR FOCUSED?

Comprehensive Assessment
Is appropriate for new pxs in
the office/hospital
Provides fundamental &
personalized knowledge about
the px
Strengthens the clinician-px
relationship

Positive impression
Appearance
Confidence
Demeanor
Body language

Avoid putting things on top of the bed

Invited guest or unwanted pest?
Respect person, space, property, family
Locate px/s
Introduce yourself handshake
Determine pxs desired name
Avoid disrespectful terms & voice tone
Consider age & culture

Identifying Data

Reliability
Chief Complaint/s

Hx of Present
Illness

Past Medical Hx

TIPS FOR EFFECTIVE HX TAKING

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

Assesses the specific body

sytems relevant to the pxs
concerns

COMPONENTS OF THE HEALTH HISTORY

*Bates

ESTABLISHING THE PATIENT RELATIONSHIP

Types of questions
Open ended Qs
What seems to be bothering you today?
Close ended Qs- BEST
Is your chest pain sharp or dull?
Multiple choice Qs
Listen actively
o Act as if you are listening
o Repeat pxs statements
o Clarify if needed
o Take notes
o Display concern
o Confront w/ caution
o Explore CC in more detail
o Explore other complaints
Are they associated?
Do they involve completely different body systems?
Subjective Data
- What the px tells you

Is appropriate for established

pxs, especially during routine/
urgent care visits
Addresses focused
concerns/symptoms

Helps identify/ rule out physical

causes related to px concerns
Develops proficiency in the
essential skills of physical
examination
*We will do the Comprehensive Assessment since were newbies.

FIRST IMPRESSIONS

Focused Assessment

Family Hx

Personal & Social

Hx
Review of
Systems

Age, gender, occupation, marital

status
Source of hx usually the px, but can
be a family member/ friend, letter of
referral, or the medical record
If appropriate, establish source of
referral, because a written report may
be needed
varies according to memory, trust, &
mood
1 sx/ concerns causing the px to seek
care
Amplifies CC, describes how each sx
developed
Pxs thoughts and feelings about
illness
Pulls in relevant portions of ROS
(pertinent +s & -s)
Medications, allergies, habits
(smoking, alcohol), w/c are frequently
pertinent to the present illness
Childhood illnesses
Adult illnesses w/ dates for medical,
surgical, obstetric/gynecologic,
psychiatric
Health maintenance practices:
Immunizations, screening tests,
lifestyle issues, home safety
Outlines/diagrams of age, health, age
& cause of death of siblings, parents,
& grandparents
Documents presence/absence of
illnesses in family (HPN, CA disease,
etc)
educational level, family of origin,
current household, personal interests,
lifestyle
Documents presence/absence of
common sx related to each major body
system

ELEMENTS OF THE COMPREHENSIVE HEALTH HX

(GUIDELINES FOR HX TAKING & PE)
I. GENERAL DATA

To Identify px

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Informant indicate, ID & give estimate of accuracy (to

determine reliability of px)
Name, age, sex, marital status, nationality, religion, occupation,
birthplace, present address, number of admission in this
particular hospital, exact date of admission
Admissions include order & locxn of admission
ER NOT an admission

II. CHIEF COMPLAINT (CC)

Prolonged sx
May not be sx of a more serious disease
Only 1 CC
Single most critical concern to px
o What prompted you to seek consultation?
o What can I help you w/ today?
o W/c sys (origin) do you believe to be affected by this CC?
o Do you clearly understand the pxs complaint/s?
Record simple statement of pxs complaint in his own words, 1few words or phrase (non-verbatim)
Description of sx should be at the HPI
Multiple complaints
o If I could make 1 thing better for you, w/c would you want it
to be?
o Are the multiple complaints likely to be related?
o Will you need to address multiple issues?
o Could some of these be chronic issues?
III. HISTORY OF PRESENT ILLNESS (HPI)

Explore CC in more detail

Explore other complaints
o Are they associated?
o Do they involve completely different body systems?
Complete, clear, & chronologic account of the problems
prompting the px to seek care
Include:
o Onset of the problem
o Setting in w/c it has developed
o Manifestations
o Any treatments
Should reveal the pxs responses to his/her sx & what effect the
illness has had on the pxs life
Medications
o Name, dose, route frequency of use
o Home remedies, nonprescription drugs, vitamins,
mineral/herbal supplements, oral contraceptives, meds
borrowed from family members/friends
Allergies
o Specific reactions to each medication (i.e. rash/nausea)
o Allergies to food, insects, or environmental factors
Tobacco use (pack-years)
o no. of packs/day x yrs of smoking = pack-yrs
o E.g. A person who has smoked 1 packs/day for 12 yrs has
an 18-pack-yr history (1 x 12 = 18)
o If someone has quit, note for how long
o Like Doc Tengco, married for 30 yrs. How many **ck years?
(Guzman, 2014)
Alcohol & drug use should always be indicated in HPI

Chronology
provides structure for organizing data, particularly when multiple
sx are present
Additional Qs related to temporal aspect of illness
o Frequency
o Periodicity
o Duration of typical episode
o Typical day/night
o Time of onset of sx (ask the last time he felt well)
Bodily locations of sx (& radiation if any)
Quantitative Qs
o Volume
o No
o Size
o Extent
Qualitative Qs
o Intensity
o Severity

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

o Comparison w/ previous experiences

Precipitating factors
Alleviating factors
Impact of illness on pxs life
o Relationships
o Exercise tolerance
o Ability to concentrate
o Athletic/leisure activities
Associated sx & info w/c might help in differential diagnosis:
o All items in pertinent system
o Qs provoked by abnormalities in PE
o Nonspecific manifestation of organic disease
o Qs provoked by etiologic possibilities
o Hx of test/procedure done to arrive at diagnosis
o Hs of previous diagnosis
o Med/drugs currently taking (religiously or not)

PQRST of Symptoms
Provocative/Palliative factors aggravates/relieves sx
Quality
Radiation common in pain
Severity (pain scale/grading) limit pxs activities
Timing onset of sx
The 7 attributes of a symptom

*Bates
(Provocative/Palliative) Remitting/ Exacerbating Factors
aggravated/relieved sx
Quality
(Radiation/) Location
Severity/ Quantity
Timing onset, duration, frequency
Setting in w/c it occurs
Associated manifestations
Pertinent positives & pertinent negatives designate presence/
absence of sx relevant to differential diagnosis
IV. PAST MEDICAL HISTORY

(Paragraph form)
Health maintenance
o Immunizations
o Screening tests (e.g. Pap smears, mammograms)
Diagnosed childhood illnesses, medications taken
o HPN: highest, lowest, regular level; were diagnosed followup consultations
Previous hospitalizations/surgical procedures, dates
reasons/indications, complications, blood transfusions, adult
illnesses
o Medical
Diabetes, HPN, Hepatitis
o Surgical
Dates, indications, types of operation
o Obstretic
Obstetric hx, Menstrual hx
Birth control, Sexual function
o Psychiatric
Dates, diagnoses, hospitalizations, treatments
Previous accident & trauma

Paragraph form
Age, health or cause of death of parents, grandparents, uncles
and aunts, and siblings (parents and siblings are the most
important)
Family incidence of HPN, DM, TB. CA. mental disease, blood
disorder
VI. PERSONAL/SOCIAL HISTORY

Paragraph form

Marital duration, health of partner

Place of birth and residence
Highest level of education
Habits:
o Regularity of eating/sleeping
o Exercise

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o Coffee
o Smoking (in pack years)
o Drugs
Occupation (past and present work
o Past and present work
o Exposure to occupational disease
o Duration of work
Personality Traits
o Outgoing
o Quiet
o Moody
Weight
o Usual weight
o History of weight loss/gain
Type of residence where patient lives
o Number of rooms and occupants
o Water source
o Fecal disposal
Neighborhood
o Congested
o Proximity to unusual place
o Buildings
Nutritional history

Gastrointestinal

Genitourinary

Hematologic

Neuromuscular

Endocrine

REVIEW OF SYSTEMS

Documents presence or absence of common symptoms related

to each major body system
Most ROS questions pertain to symptoms, but some also include
diseases like pneumonia or TB
Start with general questions as you address each system (this
focuses the patients attention), then shift to more specific
questions about systems that may be of concern.
Vary the need for additional questions depending on the patients
age, complaints, general state of health, and your clinical
judgment
ROS may uncover problems that the patient has overlooked
(unrelated to present illness)
This section should be described in detail the signs and
symptoms listed below to include
o Duration
o Severity
o Provocative and palliative factors
System
Signs and Symptoms
Head,
Eyes, Head: headache, lumps, discomforts, head
Ears,
Nose,
injury
Throat (HEENT) Eyes: vision, use of glasses, eye pain
Ears: hearing, earache, discharge, tinnitus
(ringing in the ears), vertigo
Nose: epistaxis (nose bleed), congestion,
discharge
Throat: bleeding gums, dentition, dental
caries, sore throat, hoarseness, masses in the
neck, dysphagia (difficulty in swallowing) or
odonophagia (pain produced by swallowing)
Integumentary
Skin: rashes, pruritus (itching), dryness,
lumps, sores
Hair: loss of hair, hirsutism (for women only
excessive growth of hair of normal or
abnormal distribution)
Respiratory
Pain in chest, dyspnea (difficulty in breathing),
cough, sputum (color, quantity), audible
wheezing (breathing difficultly usually with
whistling sound), hemoptysis (expectoration of
blood from some part of the respiratory tract),
night sweats, pleurisy (inflammation of the
pleura nest to the lung, last chest x-ray, you
may wish to include asthma, bronchitis,
emphysema, pneumonia, and tuberculosis
Cardiovascular Palpitation (awareness of own heartbeat),
orthopnea (inability to breathe except in an
upright position - advance HF), paroxysmal
nocturnal dyspnea, chest pain/discomfort,
edema (abnormal excess accumulation of
serous fluid in connective tissue or in serous
cavity), easy fatigability, cyanosis (bluish or
purplish
discoloration),
intermittent

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

Obstetric and
Gynecologic

claudications (cramping pain and weakness in

the legs that disappears after rest, and is
usually associated with inadequate blood
supply to the muscle; pulikat), varicosities
(prominence of the veins)
Nausea, vomiting, abdominal pain, change in
bowel habits (describe bowel habits e.g.
diarrhea,
constipation),
stools
(color,
consistency), frequency, melena (passage of
dark tarry stools containing decomposing
blood that is usually an indication of bleeding
in the upper GIT), hematochezia (passage of
blood in the feces that is usually an indication
of bleeding in the lower GIT), hematemesis
(vomiting of blood), jaundice, liver or
gallbladder trouble, etc.
Hematemesis with hematochezia sever
upper GI bleeding
Amount and frequency of urination, color, and
character or urine, dysuria (difficult or painful
urination), hematuria (presence of blood or
RBC in the urine), anuria (40cc/day), oliguria
(400cc/day), polyuria (>3L/day), nocturia
(urination > 2x/night; may suggest polyuria),
urinary retention, dribbling (continuous
dripping or urine), incontinence (involuntary
loss of urine), enuresis (bed wetting without
incontinence)
Pallor (paleness), bleeding gums (observed
after brushing teeth), epistaxis, hematoma
(mass of usually clotted blood that forms in a
tissue, organ, or body space as a result of a
broken blood vessel), hematemesis, melena,
easy bruising, prolonged bleeding
Memory loss, nervousness, insomnia, vertigo,
movement disorders (tremors, convulsions,
chorea, athetosis, etc.), joint pains, muscle
weakness/paralysis,
language/speech
problems, sensorial changes (hypesthesia,
hyposthesia, hyperesthesia, etc.)
Cold or heat intolerance
s/sx of hyperthyroidism: weight loss, increased
appetite, weakness, palpitations, diarrhea
s/sx of hypothyroidism: sluggishness, easy
fatigability, hoarseness, complaint of coldness
s/sx of diabetes: weight loss, polyuria,
polydipsia (excessive or abnormal thirst),
polyphagia (excessive appetite or eating),
pruritus, numbness of skin, recurrent pyogenic
infection of the skin
Menstrual history: menarche, menopause,
regularity, duration and heaviness of bleeding,
date of last period
Pregnancy:
number
of
abortions,
miscarriages, live births, methods of delivery,
living children
Veneraal diseases
SPECIAL CHALLENGES

Interviewing patients may precipitate several behaviors and

situations that seem particularly vexing or perplexing
Always remember the importance of listening to the patient and
clarifying the patients concerns
SENSITIVE TOPICS

The right location

o Does anyone present make the patient feel uncomfortable?
Gaining trust
Choosing appropriate words
Understand the patients feelings related to the sensitive nature
Be professional
THE SILENT PATIENT

Short periods of silence may be normal

Allow time to collect thoughts

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Provide reassurance and encouragement

Consider:
o You have frightened the patient
o You are dominating the discussion
o You have offended the patient
o There is a physical or mental disorder
THE OVERLY-TALKATIVE PATIENT

Allow patient to speak

If necessary, politely interrupt and focus the discussion
Focus on most critical issue
Ask specific, closed-ended questions
Summarize the patients story and move on
Dont display impatience

o History may be inaccurate

o Enlist friends or family
Can the patient actually read?
o Read statements aloud to the patient
THE PATIENT WITH SENSORY DEFICITS

Hearing impaired
o Does the patient read lips
Face patient, close to good ear
Talk slowly and distinctly
Sign language?
o Will a hearing aid help? Where is it?
Blindness
o Voice and touch and critical
o Establish relationship and trust early on

THE ANXIOUS OR FRIGHTENED PATIENT

Look for signs of anxiety and fear

Try to alleviate concerns and develop trust
No false reassurance
o Everything is going to be fine.
Identify the source of anxiety/fear
Understand the patients feelings
o I dont know why youre so anxious.
THE ANGRY OR HOSTILE PATIENT

Common feelings with stress or fear

Understand the source of these feelings
Respond in a professional and caring manner
Personal safety is a primary concern
o Distance
o Assistance
o Firm but caring verbal and body language
THE INTOXICATED PATIENT

Irrational
Altered sense of right and wrong
May become violent
If patient is shouting
o Increased potential for violent behavior
o Listen
o Dont respond back with shouting
o Have assistance for safety

COMMON PITFALLS

Choosing to ask a lot of

questions to obtain a history
without also directing initial
care or performing a physical
exam.
Using a tone of voice that
sends the wrong message.
What is your problem
today, Mrs. Jones?
Why did you call 911?
Lack of respect for cultural,
religious,
or
ethnic
differences.
Why do you people use
these
home
herbal
medicines?
You have enough kids. You
should
consider
birth
control.
Poor choice of words or
using technical terms.
How many years has your
husband been taking these
ACE-inhibitors?
Your wife is experiencing
congestive heart failure.

Patients Impression
Not doing anything for me
Why are we wasting our
time here?
Stop asking all these silly
questions.
He thinks I call EMS for
every little problem.
I must have called 911 and
was not supposed to.
I think I am bothering these
nice people.
This person thinks I am a
fool.
She laughs at the traditions
of my culture.
He does not respect my
personal decisions.

What the heck is he talking

about?
My wifes heart is failing?!?!
Has her heart stopped yet?
Son, could you speak
English?

THE DEPRESSED OR SUICIDAL PATIENT

Know the warning signs

Explore the specific feelings of the patient
o Be direct and specific
o Question regarding thoughts of suicide or personal harm
o Talk openly and specifically about suicide plans

SUMMARY
Obtaining the Hx guides the PE
Hx-taking is accomplished along with the PE and therapies
For emergent patients, the Hx-taking is delayed or never actually
obtained in the pre-hospital setting

THE PATIENT WITH CONFUSING BEHAVIOR OR HISTORY

The entire history does not add up

Assess mental status
Consider possible dementia or delirium
o Identify cause of possible
o Consider specific causes based upon behavior
Confabulation
Multiple personalities
Patients with frontal love tumors may manifest with psychiatric
symptoms
o Ensure neurologic examination
THE PATIENT WITH LANGUAGE BARRIER

Extremely difficult to assess

Enlist friends or family to act as an interpreter
Use pre-established questions in the patients language
Language lines
INTELLIGENCE AND LITERACY

Does the patient really understand your questioning?

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

THE PHYSICAL EXAM

The key to a thorough and accurate physical examination is
developing a systematic sequence of examination.
An important goal is to minimize the number of times you ask the
patient to change position
An initial assessment of the patient will have been made whilst
taking the history. The general appearance of the patient will be
your first observation.

GENERAL SURVEY
The survey continues throughout the history and examination.
1.

State of awareness and level of consciousness

(drowsy, stuporous, lethargic, comatose)
2. Orientation to 3 spheres
(time/person/place)
3. General state of health
4. Build
(endomorph, mesomorph, ectomorph)
5. Sexual development
6. Posture, motor activity, and gait
(coordinated, uncoordinated, staggering, shuffling, stumbling,
unable to walk alone, w/ assistive devices)
7. Signs of distress
(pain, cardiorespiratory)
8. Skin color and lesions
9. Body habits
10. Degree of nourishment

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(obese, cachexic, well-nourished)

11. Dress, grooming, and personal hygiene
12. Odors of the body or breath
13. Facial expressions
(calm, worried, restless, tense)
14. Manner of speaking and mood
VITAL SIGNS
The patient is sitting on the edge of the bed or examining table (unless
contraindicated).
1. Height and weight
> Other anthropometric measurements (if indicated: BMI, WHR,
MUAC)
2. BP (indicate if Sitting / lying / standing)
3. PR (indicate also if regular/irregular)
4. RR (indicate also if regular/irregular)
5. Temperature (if indicated: Oral / axillary / rectal)
SKIN
Continue your assessment of the skin as you examine other body
regions.
1. Observe the skin of the face and its characteristics
2. Identify the presence of any lesion/s (location, distribution,
arrangement, type, and color)
3. Inspect and palpate the hair and nails
4. Skin color (pallor, jaundice, flushing, cyanosis); temperature (cold,
slightly warm, warm -local / systemic); turgor, moisture (very dry,
sweaty , oily, moist in skin folds)
5. Study the patients hands

External Canal
Discharge
Gross Hearing
Weber
Test(lateralization)
Rinne Test

abnormalities
Impacted cerumen, lesions
Foul-smelling, serous, purulent, mucoid, color,
amount
Normal, hearing problem [R L]
Positive, negative
Air conduction >/< bone conduction

NOSE AND SINUSES

1. Examine the external nose
2. Inspect the nasal mucosa, septum, and turbinates using a light and
a nasal speculum.
3. Palpate for tenderness of the frontal and maxillary sinuses
Nasolabial
Fold
Septum
Mucosa
Discharge
Patency
Sense of
Smell
Sinuses

Symmetrical, shallow [R / L]
Midline, deviated, perforated, polyps
Pinkish, pale, reddish
Serous, purulent, mucoid, bloody
Both patent, obstructed [R / L], masses / lesions

Tender, nontender, result of transillumination

MOUTH AND PHARYNX/THROAT

You may wish to assess the cranial nerves during this portion of the
examination

HEAD, EYES, EARS, NOSE, THROAT (HEENT)

Lips
HEAD
1. Configuration (normocephalic, masses, skull deformation,
depressions)
2. Hair (fine, coarse, dry, breaks easily, color, normal distribution, bald
spot, alopecia)
3. Scalp (clean, dandruff, lice, lesions)
EYES
The room should be darkened for the ophthalmoscopic examination to
promote papillary dilation and visibility of the fundi.
1.
2.
3.
4.
5.
6.
7.
8.

Visual acuity, visual fields, color field, position and alignment

Observe the eyebrows and eyelids
Inspect the sclera, conjunctiva, cornea, iris, and lens
Compare the pupils and test their reactions to light
Extraocular movements
Inspect the ocular fundi
Demonstrate reflexes (corneal and pupillary)
Perform fundoscopy (disc, vessels, retina, and macula)

Eyelids
Periorbital
Region
Conjunctiva
Sclera
Cornea & Lens
Pupil Size
Reaction to
Light
Accommodation
Convergence
Visual Acuity

EOM
Eyebrows
Lacrimal Duct

Symmetry, edema/swelling [R / L], ptosis [R / L],

entropion, ectropion
Edema, sunken, discoloration, xanthelasma, lesions
Pinkish, pale, lesion, discharge, hemorrhage
Anicteric, subicteric, icteric, hemorrhage
Smooth, clear, lesions, opacity, arcus senilis, corneal
reflex
Equal, unequal R ___mm L ___mm
Brisk, sluggish, fixed, unequal
Uniform, unequal
Uniform, unequal
Able to read newsprint with __ font size at __
distance with [R / L / both eyes], grossly normal,
wears glasses / contact lenses, intact peripheral
visual fields
Coordinated, uncoordinated
Hair distribution
Easy tearing, tenderness, discharge, inflammation

Tongue
Teeth
Gums
Mucosa

Palate
Uvula
Tonsils
Speech
Sputum
Smooth
muscle
movements

NECK
Inspect and palpate the cervical lymph nodes
Note any masses or unusual pulsations in the neck
Feel for any tracheal deviation
Observe sound and effort of breathing
Inspect and palpate the thyroid gland. Note the size, shape,
consistency, bruit and movement upon swallowing (Move behind the
sitting patient to feel the thyroid gland)
6. Scar
Trachea
Lymph Nodes
Thyroid
Others

Midline, deviation [R /L]

Nonpalpable, palpable, enlarged, tender
Nonpalpable, enlarged: unilateral/bilateral, discrete
nodules, firmly attached, freely mobile
Normal ROM, neck rigidity, NVE at ____
masses: size, shape

BACK
Inspect and palpate the spine and muscles of the back

POSTERIOR THORAX AND LUNGS

Inspect and palpate the spine and muscles of the upper back
Inspect, palpate, and percuss the chest
Identify the level of diaphragmatic dullness on each side
Breath sounds
Adventitious sounds
Transmitted voice sounds (if indicated)

1.
2.
3.
4.
5.
6.

External Pinnae

Inspiration
Expiration

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

Tongue moves side to side, gag relfex

1.
2.
3.
4.
5.

EARS
1. Inspect the auricles, canals, and drums
2. Auditory acuity
o
If diminished, check lateralization: Weber test
o
compare air and bone conduction: Rinne test
3. Perform otoscopy, describe tympanic membrane
Normoset, symmetrical, tenderness, gross

Pallor, cyanosis, dryness / cracks, lesions, mouth

sore, cleft
Midline, deviated [R /L], atrophy, fasciculations,
lesions, color
Complete, missing, carries, dentures ,
braces/retainers
Pinkish, pale, bleeding, tenderness
Oral: Pinkish, pale, cyanotic
Pharynx: Dull red, pale, cyanotic, with exudates:
color
Lesion, cleft
Midline, deviated [R / L]
Inflammation: grade
Intact, slurred, aphasic, others
Color, amount, others

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Ratio (IE ratio)

Inspection
Breathing
Pattern
Shape of Chest
Chest
Expansion
Tactile
Fremitus
Vocal Fremitus
Breath Sounds

Pectus excavatum (hollowed chest), Pectus

carinatum (pigeon chest), lesions
Eupnea, hyperpnea, tachypnea, dyspnea, use of
accessory muscles
APL Ratio: ___AP ___L
Barrel, funnel, pigeon, others
Symmetrical, decrease / lag [R / L]
Symmetrical, inc / dec at [R / L]
Bronchophony, whispered pectoriloquy, egophony
Vesicular over: most of lungs, [R / L], I/E, pitch: low /
medium / high; absent
Bronchovesicular over: 1st& 2nd ICS, I/E,
intrascapular, pitch: low / medium / high

Adventitious
Sounds
Percussion
Excursion

Bronchial over:manubrium, lobar pneumonia, I/E,

pitch: low / medium / high
Rhonchi over, wheezes over, crackles / rales, pleural
friction rub, stridor
Resonant [R / L], dull [R / L] over, hyperresonant [R /
L] over
Diaphragmatic dullness at, respiratory excursion
around

BREAST, AXILLAE, AND EPITROCHLEAR NODES

1. In a woman, inspect and palpate the breasts (in supine position)
with her arms relaxed, then elevated, and then with her hands
pressed on her hips.
2. Note the size, symmetry, contour, color, edema, venous pattern, and
dimpling of the breasts.
3. Note the size, shape, inversions, ulcerations, discharge, and
tenderness of the nipple.
4. In either sex, inspect the axillae and feel for the axillary nodes. Feel
for the epitrochlear nodes.
Symmetry
Contour
Skin
Tenderness
Nipple and
Areola
Lymph nodes

Equal, unequal
Masses [R / L], dimpling [R / L]
Redness, edema, lesions
Tender at, nontender
Inversion, flattening / retraction, deviation to [R /L],
edema

ANTERIOR THORAX AND LUNGS

1. Inspect, palpate, and percuss the chest.
2. Breath sounds, adventitious sounds, transmitted voice sounds (if
indicated)
CARDIOVASCULAR SYSTEM
Elevate the head of the bed to about 30
1. Observe the jugular venous pulsations, and measure the jugular
venous pressure in relation to the sternal angle.
1. Inspect and palpate the carotid pulsations
2. Listen for carotid bruits
HEART
1. Inspect and palpate the precordium (note thrills, point of maximal
impulse).
2. Location, diameter, amplitude, and duration of the apical impulse
3. Listen at the apex and the lower sternal border with the bell of a
stethoscope. Ask the patient to roll partly onto the left side while you
listen at the apex.
1. Listen at each auscultatory area with the diaphragm.
2. Listen for the first and second heart sounds
3. Listen for any abnormal heart sounds or murmurs. The patient
should sit, lean forward, and exhale while you listen for the murmur
of aortic regurgitation.

1. Inspection
Scars, striae, dilated veins, rashes,
Umbilicus: contour, eversion, inflammation, hernia
Abdominal contour: flat, scaphoid, globular, masses, pulsations
2. Auscultation
Bowel sounds, gurgles, bruits, Borborygmi
3. Palpation
Deep and light palpation for masses, areas of tenderness,
ballottement, characterize mass (soft, hard, doughy)
Assess the liver and spleen by percussion and then palpation.
Try to feel the kidneys
Palpate the aorta and its pulsations.
4. Percussion
Fluid, shifting dullness, areas of dullness (liver, spleen and other
masses) Tympany, Traubes space.
For suspected kidney infection, percuss posteriorly over the
costovertebral angles.
Skin
Umbilicus
Configuration
Bowel Sounds

Bruit
Percussion

Palpation

Psoas Sign
Obturator Sign
Pregnant

Percussion

Flat, bulging, normodynamic, hyperdynamic,

tenderness, heaves / thrills, PMI at __
Normal, distension: lying ___degrees, ___cm
Easily palpable, diminution
Faint, distinct S3 S4
S1__S2 at base; S1__S2 at apex
Murmur, grade __ best heard at ____
Cardiac dullness from ___ to ___ ICS
ABDOMEN

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

Dilated veins, striae, scar, rashes, lesions

Sunken, bulging, hernia
Flat, globular, protuberant, scaphoid
Symmetrical, asymmetrical
Normoactive ____/min, hyperactive ____/min,
hypoactive ____/min
Absent, dull, medium, loud
Absent, present over _____
Tympanitic, hyperresonant over
Dull over
fluid wave
shifting dullness
Muscle guarding
Liver: tenderness, span
CVA tenderness, rebound tenderness
Splenic dullness
Aorta: palpable, well-defined mass

LMP ___wks
Fundic Height ____cm
Fetal Position and Lie: [R / L] ______________
Fetal Presentation ____________ , ballottement
FHR: ______beats/min at _________

GENITALIA
1. MEN

Patient is standing. Examiner seated on stool.

Male penis

Size, circumsized, urethral meatus, ulcers, scars, tenderness,

indurations, note scrotum and content, transilluminate; Hernia
external inguinal ring
2. WOMEN

Patient is supine in lithotomy position.

Examiner seated during speculum exam and standing during

bimanual exam of uterus and adnexa.

Female external genitalia

Labia majora, minora, clitoris and urethral orifice

Bimanual examination of vagina, cervix, uterus, adnexae,

rectovaginal pouch

Obtain Pap smear.

Pericordial
Area
Jugular Veins
Carotid
Arteries
Heart Sounds

Examine with the patient in supine. Examiner standing on the right

side of bed.
Inspect, auscultate, palpate and percuss.

RECTUM
Men: patient is lying on his left side; examiner standing
Women: patient is supine in lithotomy position; examiner is
standing.
Inspect anus and perianal area. Note lumps, inflammation and
rashes. Ask patient to strain down and note hemorrhoids, fissures
and other lesions
Digital exam: note sphincter tone of anus, tenderness, nodules.
Examine prostate, size, shape, consistency, nodularity and
tenderness
PERIPHERAL VASCULAR SYSTEM
Upper: symmetry, nail beds, color
Pulses: brachial, radial, ulnar
Lower: symmetry, nail beds, color and edema; examine legs,
assessing three systems while patient is supine.

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-Pulses: femoral, popliteal, dorsalis pedis, posterior tibial,

varicosities
MUSCULOSKELETAL SYSTEM
Evaluate each joint for:
1.
2.
3.
4.
5.
6.

Limitation of normal range of motion

Swelling
Deformity
Crepitation
Strength
Muscle atrophy
By this time, you have made some preliminary observations of the
musculoskeletal system. Use these and subsequent observations
to decide whether a full musculoskeletal examination is warranted.
Examine the hands, arms, shoulders, neck, and
temporomandibular joints.
Inspect and palpate the joints. Check their range of motion.

NERVOUS SYSTEM
The complete examination of the nervous system can be done at the
end of the examination.
MENTAL STATUS
Assess the patients orientation, mood, thought process, thought
content, abnormal perceptions, insight and judgment, memory
and attention, information and vocabulary, calculating abilities,
abstract thinking, and constructional ability.

CRANIAL NERVES

Check sense of smell, strength of the temporal and masseter

muscles, corneal reflexes, facial movements, gag reflex, and
strength of the trapezia and sternomastoid muscles.
MOTOR SYSTEM
Muscle bulk, tone, and strength of major muscle groups.

USE OF COGNITIVE SHORTCUTS

Also called heuristics or rules of thumb
a type of intuitive mental process that help solve clinical
problems with great efficiency

1. REPRESENTATIVENESS HEURISTIC

DESCRIPTION
Clinician is searching for
the diagnosis for which the
patient appears to be a
representative
Makes use of the Patient
history
Allows efficient , directed,
and therapeutically
productive Patient
evaluation
Analogous to pattern
recognition

SENSORY SYSTEM
Pain, temperature, light touch, vibration, and discrimination.
Compare right with left sides and distal with proximal areas on the
limbs.

ERRORS ENCOUNTERED

Failure to consider the

underlying prevalence of
2 competing diagnoses
Failure to consider that a
pattern based on a small
number
of
prior
observations will likely be
less reliable than one
based on larger samples

Example:
A patient with pleuritic chest pain, dyspnea, and a low-grade
fever. A clinician might consider acute pneumonia and acute
pulmonary embolism to be the two leading diagnostic
alternatives. Using the representativeness heuristic, the clinician
might judge both diagnostic candidates to be equally likely ,
although doing so would be wrong if pneumonia was much more
prevalent in the underlying population.
2. AVAILABILITY HEURISTIC

DESCRIPTION

CEREBELLAR FUNCTION
Check rapid alternating movements (RAMs), point-to-point
movements, such as finger-to-nose (F N) and heel-to-shin (H
S); gait.

2. Use of diagnostic hypotheses to consolidate the information

and indicate appropriate management steps.

Involves
judgments
made on the basis of
how easily prior similar
cases can be brought to
mind

ERRORS ENCOUNTERED

Recall bias
Rare catastrophes and
more recent experiences
are more likely to be
recalled

Example:
An experienced physician may recall a previous incident
where he encountered a particular symptom. It would take some
time for a novice practitioner to come up with a diagnosis.
3. ANCHORING HEURISTIC

DESCRIPTION

DECISION MAKING IN CLINICAL MEDICINE

EVIDENCE-BASED MEDICINE

describes the integration of the best available research

evidence with clinical judgment and experience in the care of
patients.
changes with time, research, and evidence
CLINICAL REASONING

The most important actions in medicine are not procedures or

prescriptions but judgments (diagnoses and treatment)
Research on medical expertise is best developed in the area of
diagnostic decision making
How to compute for the Pack Years?
Pack Years = No. of cigarette pack/s per day x No. of years
he/she is
smoking
ex.

Involves estimating a
probability by starting
from a familiar point
(anchor)
Powerful tool for
diagnosis
Very accurate, greater
precision and specificity
Looks at pretest
probability and risk
factors

ERRORS ENCOUNTERED

Often used incorrectly

Pretest
probabilities
should be accounted for

Example:
A doctor may judge the probability of Coronary Artery
Disease to be very high after a positive exercise thallium test
because the prediction has been anchored to the test result
("positive test = high probability of CAD" ). But prediction would
be inaccurate
if the clinical (pretest) picture of the patient being tested indicated
a low probability of disease (e.g., a 30-year-old woman with no
risk factors).

Pack years = 2 packs per day x 10 years of smoking

Answer = 20 pack years

In Harrisons
4. SIMPLICITY HEURISTIC

DESCRIPTION

Pack years = 10 cigarette sticks per day x 10 years of smoking

CLINICAL DECISION MAKING

(Note: 1 pack = 20 cigarettes.)

1. Use of cognitive shortcuts as a way to organize the complex
Thus, 10 material
cigarettes
= 0.5
pack perinday
unstructured
that
is collected
the clinical evaluation.
Answer = 5 pack years

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

ERRORS ENCOUNTERED

clinicians should use

the simplest explanation
possible
that
will
account adequately for
the patient' s symptom

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Introduction to
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s or findings (Occam's
razor).

USE OF DIAGNOSTIC HYPOTHESES

Cognitive shortcuts play vital role in hypothesis generation
Sets a context for diagnostic steps to follow
Provides testable predictions
Expert clinicians do not follow fixed pattern in Patient
examinations
Questions asked in the history and PE are driven by the
hypothesis
Clinician is on a focused search mission
Negative findings are as important as positive ones!
Acuity of patients illness play important role in overriding
considerations of prevalence and other issues
Non-acute conditions: prevalence of alternative diagnoses
should play more prominent role in Diagnosis hypothesis
generation.

GENERATION OF DIAGNOSTIC HYPOTHESIS

relate to physical resources available

physician-induced demand: refers to the remarkable ability
to accommodate to and employ the medical facilities available
to them
also affected by availability of specialists and high tech
facilities (e.g. mri, angiography suites, surgery program, etc)

3.

True-positive rate (sensitivity) = TP/(TP + FN)

False-negative rate = FN/(TP + FN)

influenced by physicians knowledge, training ,experience,

recollection and interpretation of available medical evidence.
practice style also depends on the physicians specialization
or area of expertise
specialists have more familiarity with specific drugs and
processes in their area of expertise and are less likely to
overreact to foreseeable problems in therapy
also influenced by opinion of influential leaders (need not to
be doctors)
Defensive Medicine: Decision making is affected by the
physicians perception about the risk of malpractice suit.
Involves using tests and therapies with very small marginal
returns to preclude future criticism
FACTORS RELATED TO THE PRACTICE SETTING

Identification of patients with disease

PERSONAL

2.

Specificity or true-negative rate

proportion of patients without disease who have a negative test
reflects how well the test correctly identifies patients without
disease
low probability of having the disease

Table 3-1 Measures of Diagnostic Test Accuracy

Disease Status
Test Result
Present
Absent
Positive
True-positive (TP) False-positive
(FP)
Negative
false-negative (fn) true-negative (tn)

Errors can occur that can lead to serious consequences

patient can diverge from textbook symptoms and the potential
consequences of being unable to adapt to the diagnostic
process to real-world challenges.
Real clues should be distinguished from false traits
High alert for clues that the initial Diagnosis may be wrong

FACTORS RELATED TO PHYSICIANS

CHARACTERISTICS AND PRACTICE STYLE

Sensitivity or True-Positive Rate

proportion of patients with disease (defined by the gold
standard) who have a positive (new) test
reflects how well the test identifies patients with disease

A perfect test would have a sensitivity of 100% and a specificity

of 100% & would completely separate patients w/ disease from
those without it.

MAJOR INFLUENCES ON CLINICAL DECISION MAKING

1.

The purpose of performing a test on a patient is to reduce

uncertainty about the patient's diagnosis or prognosis and aid
the clinician in making management decisions
The accuracy of diagnostic tests is defined in relation to an
accepted "gold standard"

True-positive rate = 1 false-negative rate

Identification of patients without disease

True-negative rate (specificity) = TN/(TN + FP)
False-positive rate = FP/(TN + FP)
True-negative rate = 1 false-positive rate

Good Test:
sensitivity
=

specificity, then (+) test result

probability of having the disease

FACTORS RELATED TO ECONOMIC INCENTIVES

closely related to other two categories
financial issues can exert both stimulatory and inhibitory
influences on clinical practice
Fee-for-service: more work, more pay, doctors increase the
number of services
Capitation: provides fixed payment per patient per year,
more patients but with fewer services provided
Salary basis: receive the same amount regardless the
amount of work done

QUANTITATIVE METHODS TO AID CLINICAL

DECISION-MAKING
Defining the available courses of action and estimating the
likely outcomes with each
Assessing the desirability of the outcomes
Expert clinical decision making can be appreciated as a
complex interplay of cognitive processes(to simplify and
organize information) and physician biases (reflecting
education, training and experiences) all shaped by external
forces.

Test yourself!
sensitivity

specificity, then (-) test result

= _____ probability of having the disease

MEASURES OF DISEASE PROBABILITY AND BAYES

THEOREM
there are no perfect tests. After every test is completed, the
true disease state of the patient remains uncertain
Bayes theorem: provides a mathematical way in quantitating
this uncertainty from three parameters:
o pretest probability of disease
o test sensitivity
o test specificity
o likelihood ratio is the ratio of the probability of a given
test result (e.g., "positive" or "negative") in a patient with
disease to the probability of that result in a patient without
disease

MEASURES OF TEST ACCURACY

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Positive test: the likelihood ratio is calculated as the ratio of

the true-positive rate to the false-positive rate
[or sensitivity/(1 specificity)]
o For example, a test with a sensitivity of 0.90 and a
specificity of 0.90 has a likelihood ratio of 0.90/(1 0.90),
or 9. Thus, for this hypothetical test, a "positive" result is 9
times more likely in a patient with the disease than in a
patient without it.
o Most tests in medicine have likelihood ratios for a positive
result between 1.5 and 20. Higher values are associated
with tests that are more accurate at identifying patients
with disease.
Negative test: likelihood ratio is the ratio of the false negative
rate to the true negative rate
[or (1 sensitivity)/specificity]
o The smaller the likelihood ratio (i.e., closer to 0) the
better the test performs at ruling out disease

MEASURES OF DISEASE PROBABILITY

Pretest probability of disease = probability of disease
before test is done
o May use population prevalence of disease or more
patient-specific data to generate this probability
estimate.
Posttest probability of disease = probability of disease
accounting for both pretest probability and test results. Also
called predictive value of the test.

BAYES' THEOREM: Computational version

Posttest Probability = Pretest probability x test sensitivity
Pretest probability x test sensitivity
+ (1- pretest probability) x test falsepositive rate
Example:
[with a pretest probability of 0.50 and a "positive" diagnostic
test result (test sensitivity = 0.90, test specificity = 0.90)]:
Posttest Probability= _______(0.50) (0.90)________
(0.50)(0.90) +(0.50)(0.10)
= 0.90

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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