• Chief Complaint

• History of Present Illness

• Past Medical History
• Medications
•
•
Allergies
Review of Systems THE MEDICAL HISTORY
• Family History
•
•
Social History
Physical Exam
AND
•
•
Labs & other studies
Problem list
PHYSICAL EXAM
• Discussion/Assesment
/Plans
Preparation

Establish rapport

Identify the reason for the

consultation
Establishing
rapport
Greeting • Initial greeting

• Introduce
Introduce
yourself

• State the reason

State
you are there

Seek • Seek consent

 • How can I help you?
Open
question
• You said you have back pain, which movement makes it worse?

• Are you still taking the medication for back pain?

Close
question
• Beside your back pain, any other pain?

• You are not allergic to anything, right?

Leading
question
• Do you feel backpain when the weather is cold?
 Providing false
reassurance: “don’t
worry we will take
Talking to
much
make
care of it” eye Relaxed
contact
Open
body
position
 History of Present Illness
• Chief Complaint in “patient’s own words”, one clear sentence
cardinal symptoms
Location,intensity,quality,onset,radiation,alleviates,aggravates,
associated symptoms- LIQORAAA
• Chronological story beginning with state of health
• Incorporate elements – PMH,FH,SH relevant to story
• ROS pertinent to CC are included in HPI at the end.
• HPI narrative flows logical ,highlightning risk factors and
aspects of PMH pertinent to the CC
Cc ”sepparate anxious parents from
actual problem challenge”” Pediatric history
HPI
PMH:
- birth hx:weihgt,gestational
age,complications, congenital defects
- Pos natal hx
- Nutritional hx
- Immunization hx
- Growth & development
Family hx: living arrangement,diseases
Social hx: second hand smoking?,
environment
Includes brand®/generic names of
medications, dose, route, frequency
Includes over the counter-OTC
Herbal medicine
Infusions
Compound pharmacy
Natural medicine
 Living Ocupation
status and
function

Substance Marital
abuse status

Tobacco
ETOH
use
 Physical Exam
• CHF
• e.g • *JVD, crackles,
• “8 x 10 cm round murmur, gallops,
area of Focus hepatojugular
reflex, peripheral
Does not erythematous,
warm skin on
detailed edema, cough,
include medial aspect of RT description reduce tolerance to
Interpretation leg “ physical activity ,etc
• Instead of of findings • Explanation ,seek
• “cellulitis on medial consent
aspect of RT leg” • Keep privacy
• Chaperone.
Neurologic and MSE
Eye

Verbal

Motor
 Start always inspecting. Make a
mental picture of what you see
Auscultate the 4 quadrants ,living the
last where it hurts
Percussion up to down and side to
side. Move your head closer to
register the sounds produced by your
tapping
Palpate the last
Lab studies and others

Adequately
Appropriate Timely
reported e.g
labs for HPI reported
EKG intervals
History and Physical Examination (Current Clinical Strategies) and it was written by Paul D. Chan, MDTate P; The
Doctor's Communication Handbook (5th ed.), Radcliffe Publishing, 2003.
Illustrated Textbook of Paediatrics (4th ed) 2011
Lecture Notes in Emergency Medicine (4th ed) 2012
Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet.
2003;362(9390):1100-1105. [Context Link]

Rathe R. The complete physical. Am Fam Physician. 2003;68(7):1439, 1443-1444. [Context Link]
Stanford medicine 2010 special report. The healing hand: putting the physical back in the physical exam.
http://www.abrahamverthese.com/.../s_t_a_n_f_o_r_d___m_e_d_i_c_i_n_e.pdf. [Context Link]
AAFP News Now. AAFP releases second choosing wisely list of tests, procedures that physicians, patients should
question. http://www.aafp.org/news-now/health-of-the-public.html. [Context Link