Welcome to

Mosbys Guide to
PHYSICAL EXAMINATION,
6th edition

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 1

Chapter 1
The History and Interviewing Process

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 2

The Partnership with the Patient

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 3

 Partnership with the Patient

The History and Interviewing Process

The history and physical examination begin,

and are at the heart of, the diagnostic and
treatment process.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 4

Communicating with the Patient

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 8

 Communicating with the Patient

Factors That Enhance Communication

Basic Requirements of Healthy

Communication

Flexibility
Specificity
Clarity
Subtlety
Empathy

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 9

 Communicating with the Patient

Communication Tensions

Intimacy
Compassion

Seduction
Anger

Dissembling
Money

Curiosity about you

Anxiety
Silence
Depression
Crying
Manipulation

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 10

 Communicating with the Patient

Children

Pay attention to them

(equal emphasis on the child and on the
accompanying adult).
Play with them.
Be sensitive to their needs.
Glean clues about family dynamics.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 11

 Communicating with the Patient

Adolescents

Respect need for confidentiality.

Respect impending adult status.
Dont force conversation.
Establish an alliance.
Be flexible in approach.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 12

 Communicating with the Patient

Pregnant Women

View health needs of mother and fetus.

Explore effects of pregnancy on health status.
Use interview as time for teaching health care
practices.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 13

 Communicating with the Patient

Older Adults

Watch for age-related changes that may

impede interview (e.g., sensory loss, visual
impairment, cognitive impairment, or memory
loss).
Draw on persons cumulative lifetime
experience, wisdom, and perspective.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 14

 Communicating with the Patient

Patients with Disabilities

Adapt interview approach to fit needs.

Involve persons to limits of their ability.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 15

The History
Taking the history usually begins your
relationship with the patient.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 16

 The History

Setting for the Interview

Comfort for all involved

Removal of physical barriers
Good lighting
Privacy
Relative quiet
Unobtrusive access to clock

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 17

 The History

Structure of the History

Chief complaint
Present problem
Past medical history
Family history
Personal/social history
Systems review

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 18

 The History

Taking the History (1)

Introduce yourself.
Address patient properly.
Be courteous.
Make eye contact.
Dont overtire patient.
Dont be judgmental.
Be flexible.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 19

 The History

Taking the History (2)

Avoid medical jargon.

Take notes sparingly.

Avoid leading questions.

Start with general concerns, then move to

specific descriptions.

Clarify responses with where, when, what,

how, and why questions.

Verify and summarize what you have heard.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 20

 The History

Approaching Sensitive Issues

Ensure privacy.
Be direct and firm.
Dont apologize for broaching the issue.
Dont preach.
Use language that is understandable.
Dont push too hard.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 21

 The History

Sensitive Issue Examples

Alcohol and drug use

Religion
Sexual history
Sexual orientation

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 22

 The History

History-Taking Outline

Chief complaint
Present problem
Past medical history
Family history
Personal/social history
Systems review

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 23

 The History

Chief Complaint

Note all significant complaints.

Seek answer to the question What underlying

problems or symptoms brought you here?

Determine the duration of the current illness by

asking How long has this problem been
present?
Or When did these symptoms begin?

Note age, gender, marital status, occupation,

and previous hospital admissions.
Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 24

 The History

Present Problem or Illness:

Explore the following

Chronology of events
Health state before
present problem
First symptoms
Exposure to infection
or toxic agents
Typical attack
Illness impact on
lifestyle

Stability of problem
Immediate reason
for visit
Review of involved
systems
Medications list
Chronology review
Problem list

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 25

 The History

Past Medical History:

Explore the following

Past medications
Allergies (drugs,
environment, food)
Past transfusions
Emotional status
Use of
complementary and
alternative health
and medical
systems

General health
Childhood illnesses
Major adult illnesses
Immunizations
Surgery
Serious injuries and
resulting disability
Functional ability
limitations

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 26

 The History

Family History:
Explore the following

Family members with illness similar to

patients

Family members ethnicity, health, and/or

cause of and age at death

Family members with history of major

disease

Family members with hereditary disease

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 27

 The History

Personal and Social History:

Explore the following

Personal status
Habits
Sexual history
Home conditions
Occupation

Environment
Military record
Religious preference
Cost of care

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 28

 The History

Review of Systems:
Explore the following

General constitutional
symptoms
Diet

Skin, hair, and nails

Musculoskeletal

Head and neck

Endocrine

Chest and lungs

Heart and blood

vessels
Hematologic
Lymph nodes
Gastrointestinal
Genitourinary
Neurologic
Psychiatric

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 29

 The History

General Constitutional Symptoms

Fever
Chills
Malaise
Fatigability
Night sweats
Weight change

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 30

 The History

Diet

Appetite
Likes and dislikes
Diet restrictions, cultural constraints
Vitamins and other supplements
Caffeine
Dietary recall

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 31

 The History

Skin, Hair, and Nails

Rash, eruption, itching

Pigmentation or texture change
Excessive sweating
Abnormal nail or hair growth

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 32

 The History

Musculoskeletal

Joint stiffness, pain

Restriction of motion
Swelling, redness, heat
Bony deformity

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 33

 The History

Head and Neck: General

Headaches
Dizziness
Syncope
Head injuries
Loss of consciousness

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 34

 The History

Head and Neck: Eyes

Acuity
Blurring
Diplopia
Photophobia
Pain

Vision changes
Glaucoma
Eye medications
Trauma

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 35

 The History

Head and Neck: Ears

Hearing loss
Pain
Discharge
Tinnitus
Vertigo

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 36

 The History

Head and Neck: Nose

Sense of smell
Colds
Obstruction
Epistaxis
Postnasal discharge
Sinus pain

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 37

 The History

Head and Neck: Throat and Mouth

Hoarseness or change in voice

Sore throats
Bleeding gums
Tooth abscesses, extractions
Soreness or ulcers of tongue/mucosa
Taste changes

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 38

 The History

Endocrine: General

Thyroid enlargement
or tenderness
Heat/cold
intolerance

Weight change

Diabetes

Polydipsia

Polyuria

Changes in facial or
body hair

Increased hat or
glove size

Skin striae

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 39

 The History

Endocrine: Female and Male

Female:
Menses
Intercourse
Birth control
Pregnancy
Menopause
Breasts

Male:
Puberty onset
Erections
Emissions
Testicular pain
Libido
Infertility

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 40

 The History

Chest and Lungs

Pain

Sputum

Dyspnea

Hemoptysis

Cyanosis

Night sweats

Wheezing

Cough

Exposure to
tuberculosis

Last chest radiograph

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 41

 The History

Heart and Blood Vessels

Chest pain

Hypertension

Palpitations

Dyspnea

Previous myocardial
infarction

Orthopnea

Exercise tolerance

Edema

Claudication

Date of last
electrocardiogram

Other cardiac tests

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 42

 The History

Hematologic

Anemia
Tendency to bruise/bleed easily
Thromboses
Thrombophlebitis
Blood cell abnormalities
Past transfusions

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 43

 The History

Lymph Nodes

Enlargement
Tenderness
Suppuration

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 44

 The History

Gastrointestinal

Changes in stool
Flatulence

Hemorrhoids
Jaundice

Dark urine
Previous radiographs

Food intolerances
Dysphagia
Heartburn
Nausea/vomiting
Hematemesis
Regularity of bowels

Appetite

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 45

 The History

Genitourinary

Sexually transmitted
infections

Polyuria

Hesitancy

Dysuria

Dribbling

Pain

Loss in force of stream

Passage of stone

Edema of face

Urgency

Frequency

Stress incontinence

Nocturia

Hernias

Hematuria
Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 46

 The History

Neurologic

Syncope
Seizures
Weakness or paralysis
Abnormalities of sensation or coordination
Tremors
Loss of memory

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 47

 The History

Psychiatric

Depression
Mood changes
Difficulty concentrating
Nervousness
Tension
Suicidal thoughts
Irritability
Sleep disturbances

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 48

 The History

Concluding History Questions

Is there anything else that you think would be

important for me to know?
What problem concerns you most?
What do you think is the matter with you?
What worries you the most about how you are
feeling?

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 49

 The History

Modifications for Special Groups

Children
Adolescents
Pregnant women
Older adults

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 50

 The History

Children:
Explore following issues

Mothers gestational history, pregnancy, and birth

Childs neonatal period, feeding, and
developmental milestones
Childs school adjustment, habits, and home
conditions
Review systems for child-specific conditions

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 51

 The History

Adolescents

Factors impacting history taking:

Self-esteem, acceptance by peers, tension with

parents

Cover issues of special concern

(Hint: use mnemonic HEADS or PACES to zero in

on issues)
H1 Home Environment E2 - Education Exercise
A3 Alcohol Activities Attitudes about life D4- Diet
Drugs Dentist Depression S5- Sleep Safety Sexual
Identity & Activity Stressors Suicidal Ideation
Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 52

 The History

Pregnant Women (1):

Explore following issues

Current pregnancy and obstetric history

Exposure to environmental/occupational hazards
Family genetic conditions/congenital
abnormalities

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 53

 The History

Pregnant Women (2):

Explore following issues

Personal and social issues of pregnancy and

parenting
Reproductive, cardiovascular, endocrine,
respiratory system focus
Risk factors that threaten mother and fetus

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 54

 The History

Older Adults

Older adults may have multiple overlapping

health problems.
Chronic symptoms may not be reported.
Complete drug assessment is essential.
Assessment of functional capacity is key.

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 55

 The History

Kinds of Histories

Complete
Inventory
Problem or focused
Interim

Mosby items and derived items 2006, 2003, 1999, 1995, 1991, 1987
by Mosby, Inc. an affiliate of Elsevier Inc.

Slide 56