History and Physical Examination

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					History and Physical Examination

Format for History copy will be handed out

general data
         o Full Name
         o Age
         o Sex
         o Civil status
                 Single, married, divorced, widowed
                 Gives sexual activities of the patient
                 Social history
         o Occupation
                 Gives clue to pt's physical activity, exposure to stress
                 Pollution, agents, chemicals
                 Example
                        If you work in a company and you frequently use
                          computer, you will have eye problems; headache, back
                          pain, problem in the wrist
         o Nationality
                 Other disease only particular with that group of people
                 Sickle cell common with blacks
                 Crohn's -- whites
                 Gastric ca - chinese
         o Religion
                 Other patients who have some beliefs/traditions that's different
                   from ordinary
                        Jehovah's witness - scheduled for surgery; requires
                          blood transfusion; cannot perform that on him; it can be
                          life-threatening; need to convince the relatives to sign
                          the consent
                 Muslims don't eat pork
                 Hindus - no beef and veal (hamburgers)
         o Address/residence
         o Number of times admitted/seen by you in that hospital
                 How frequent patient hospitalized
                 Some idea of patient's problem
                        Has records
         o Date patient was admitted
         o ---substitution
         o To identify patient; to get in touch with him/her if you want to
             communicate or see him again

Chief Complaint
         o If it's a previous diagnosis, like diabetes (don't write this as chief
                 You ask about problem pertaining to diabetes; need to have
                    knowledge of diabetes to know if patient is really suffering from
                         High blood sugar, frequent urination (hyperosmolar conc.
                           Of body fluids), take in a lot of fluids
                         Lack insulin - tend to eat a lot (polyfadia)
                         Complications
                                    Neuropathy =
                                    Atherosclerosis - blood vessel of nerves so there
                                     will be some neurosensory problems (neuropathic
                   Don't place diagnosis of previous doctor; it will probably
                      mislead you to your own diagnosis because you'll miss a lot of
                      clues to the patient if he comes to you with "diagnosis"
          o   Main reason why patient came to you
          o   One ward/2 wards
          o   Difficulty of breathing
          o   Headache
          o   Chest pains
          o   Nausea/vomitting/diarrhea
          o   Loose bowel movement
          o   Need to assess main reason why patient came to you

          o   Can be long
          o   Like fever, body malay, loss of app, progressively serious --- cough,
              difficulty of breathing-----pt became alarmed ---needed to be
                    Turning point -- difficulty of breathing

History of the present illness
          o Most important part
          o During interview, ask the question "What's the problem?"
                  How did it start? Yesterday
                  Get the time interval from this
                  To clarify the symptoms
                        Categorize it into medical term that can be
                           understandable to you
                                I feel weak -- very vague condition
                                       Do you feel weak like it's paralysis? Or
                                         muscles can't move? --- get idea that
                                         weakness is a neuro problem
                                       Is it one sided or both?
                                              Weakness can be bi or unilateral
                                              Metabolic problem like dehydration,
                                                 loss of Na/K will you weak
                                              If one sided, then it's a neuro
                                                 problem, that side of nerve
                                Weakness - muscle pain
                                       Exercise too much; exerted too much;
                                         painful when you move; weak muscle
                                         because all energy used up
                                              So maybe just fatigue

                           Dizziness
                                Common problem among us
                                "I feel dizzy" Is too vague
                                "I'm falling on one side" ----more feeling of
                                   instability (disequibrilation)
                                Check what maintains the balance, eyes,
                                 middle ear and muscle
                      Whirling sensation - movement around an axis
                              Do you feel like you're whirling?
                                       If yes, then VERTIGO (middle ear
                 Swelling
                      Of particular muscle/skin, extremities
                      Edema - accumulation of interstitial fluid in the
                         interstitial space
                              Usually bilateral; affects both part of body
                              Swelling due to inflammation/infection
                                 caused by a microorganism, allergy, insect
                                       But it's actually an inflammation
                                       Swelling due to infl is one side,
                                         but edema is bilateral ---
                                         confined to most depended part
                                       If standing up -- legs
                                       If lying down -- flanks
                                       Give diarrhetics/stand up
                              Lack of sleep
                                       Puffiness
                                       Once you stand up, fluid comes
                                         back down

          Have to read to be able to know symptoms of particular

o   Narrative part
        Should be written in chronological order; to know how pt's
           problem developed
        During the interview, the patient got carried away with the
           different stories not related with the problem
                Cut him short and make him go over important topics
                Need to screen uneccessary datas

o   To quantify symptoms
        Dyspnea - difficulty of breathing
                What kind of work will make you feel dyspnic? Do you
                  feel dyspnic even at rest? That's more serious problem
                After strenuous activity
                       Example - if you climb stairs makes you feel
                       Each of us has difference of tolerance to different

          Fluid loss
                Vomitting, diarrhea, perspiration
                How to quantify
                       Frequency of vomitting or bowel movement
                      Approximate amount of vomit or loose bowel
                     Most of the time, patients don't vomit in a cup or
                       measuring container -- so you have to let him
                 Hemoptosis
                     Coughing of blood
                     Important because it gives you a clue of severity
                       of bleeding

o   Chronology
        Sequence of events
        Duration
        Frequency and time interval
        At the end, we'll ask someone to be subject

o   Pain
          Symptoms
          P - one that precipitated the pain
                Example - chest pain; before you experience it, what
                  have you been doing? Lift heavy object? Quarrel with
                  boyfriend? Was it just sudden? Were you awaken with
                       Relieved by resting or just stopping the work
                       Angina type of pain -- related to the heart; when
                         you work it makes the heart work harder; if you
                         rest it gives more time to be oxygenated
                              Subject the patient to ECG exam
                              Give oxygen to relieve hypoxia
                       If emotional stress (quarrels, surprised, happy)
                              Give comfort, sedatives
                       If had history of trauma or engaged in exercise,
                         pt had localized pain then it's musculoskeletal
                         type of chest pain (coughing with phlegm, as
                              Give analgesic, massage or give
                       If pulmonary
                              antibiotics
          Q - Quality
                Important
                Tell us about headache?
                       Throbbing? Pulsating? Constricting type of pain?
                              Throbbing - vascular type
                                      Migraine - cerebral blood vessel
                                         becomes dilated
                                             Give vasoconstrictor to
                                               relieve dilatation
                                                    compressing
                                                       vascular parts of
                       Constricting
                         Knee - muscle spasm; muscle contraction
                          headache (tension headache)
                        Touch head or knee - very tense (spastic)
                          not soft/relaxed
                               Give muscle relaxant
         Epigastric pain
                Problem with my stomach. Can you point it to
                   me? If patient can point, then you can specifically
                   determine what part of abdomen is affected; if
                   vague, then maybe muscles involved
                Quality
                        Anong nararandaman mo?
                        If can't relate in more specific terms, you
                          provide the clue (burning -- mahapde) --
                          hyperacidity --peptic ulcer, hyperacidity --
                          --give antacid
                        Feeling of coleti pain
                               Painful contraction; relieved when
                                 muscle relaxed
                               Waning/waxing pain
                               Give antispasmodic to relieve the
   R - region
         What area is the pain?
         Divide the abodmen into 4 quadrants
                Middle at the level umbilicus
                If head, frontal, temporal, parietal, occipital
                Face
                        Maxillary, mandibular, orbital
         Is it localized/generalized?
                Referred pain
                        Epigastric pain ---- it is referred at the
                        Have pain in lower quadrant (R/L ) ---pain
                          referred to legs or scrotum like in ureteral
                        Anginal pain - sternal ----referred pain
                          leading to left arm or even to the jaw
   S - Severity
         Does the pain make you incapacitated? Can't work?
         Bearable/tolerable, intolerable
         Intermediate classification of moderate hard to
           determine from sever
   T - Time
         Specify duration; How long headache? How frequent
         Chest pain
                Don't last more than one hour
                Maybe patient is suffering from infarction or heart
         Interval
                Asthma - time between the attacks
          o   What did you do after you have these symptoms?
                 What was the generic name of the drug he self medicated with?
                 Look it up in the book to know what the drug was intended for
                         Research and become familiar with these meds
                 Did you take it with the right dosage? Did you take it with right
                    frequency? With what food?
                 What happened after you took it? Were you relieved?
                 Did you have any consultation? What was done? What was the
                    work up?
                         I had ECG done; don't rely on that
                         Have to ask the official result

                 Recurrence -describe symptoms
          o   What made you decide to see me? Or go to the hospital?

Past Medical History
          o Can have your checklist with you
                   Makes work
          o When you go to ward, you assign the interviewer
                   Next person will have a chance in the group
                   Too confusing if all ask questions at the same time
                   One member can suggest a question for the interviewer to ask
          o Start with childhood
                   Measles, mumps, chickenpox
                          Immunization - have to specify.
                                 BCG - for TB; boosts immune system
                                 MMR - meales mumps rubella vaccine
                          Hep vaccines in older children
                                 Hepa A
                                 Hepa B
                   Be familiar with the vaccination/immunization schedule
                          Patient says he had complete vaccination, but it was
                            really measls one
                          Hepatitis - given 3 times; did you have booster shots?
                          Allergies - like food, drug, or any other like dust pollens,
          o Hospitalization
                   Previous surgeries - what was done, what was the outcome
                          Previous appendectomy in 2003 in St. Luke's Med
                   If patient cannot recall, you approximate then that patient not
                     able to recall specific reason/operation
                   Surgical operation of uterus, but pt can't recall what was done
                   Once you look at the scar, if doctor is familiar, he will see scar
                     at the midline (previous C section) -- right lower quad
                     (appendectomy ) -- r upper (colonectomy)

Family History
         o   Want to know if there are other heredofamiliar diseases present in the
                  Have to check out the parents, brothers and sisters -- are they
                     healthy? Age? Status? Death in the family? Cause of death?
                           Patient not sure - -said old age ---- complications of old
                             age -- immune system becomes weak -- pneumonia
         o   Common heredo illnesses
                  Patient will just say yes or no
                           Hypertension? Diabetes? Cancer? Goiter present in the
                           Father side? Mother side? Both?
         o   Familial illnesses
         o   Hereditary vs. familial
                  Hereditary --- genetics
                  Familial - anyone that is part of family not necessarily a
                     relative; friend, helper ---communicable illness
                           Tuberculosis, leprosy, syphilis

Personal/Social History
         o Start with educational background of patient
                College grad, medical school grad
                No formal ed, just finished 2nd year college/high school
         o Job/occupation
                Previous work, what made you stop? Too rigorous?
                Duration of employment
         o Position in family
         o Marital status
         o Are there any habits? Nutritional?
                Fond of fatty foods? Salty foods? Vegetarian? Eat on time?
         o Home condition
                Did patient live in squatter area? Crowded area?
                Proper ventilation, water supply
                Travel to indigenous areas like the mountains; areas wherein
                   endemic for certain diseases
                Valenzuela --- endemic for scchistemiasis - farmers wade in
                   mud infested with parasite

OBGYN history
        o Concerned with female patients
        o Inquire about menarche - first year of menstruation
               What age? 12 years old
                     Flow - mild, moderate?
                     How many napkins used per day to quantify the flow?
               Duration of menstruation
                     How many days? Usually 3-5 days. If more than one
                        week, already prolonged
                     If you have prolonged bleeding, have anemia (iron
               Hypogastric pain
                     Dysmenorrhea
                     Endometriosis
          o   What age did the menses become regular?
          o   Any history of amenoria or absence of menstruation
                  Ask about the OB score
                         G - ravida -- number of preg
                                How many times pregnant? 7
                         P - parity -- number of delivered viable pregnancies
                                5
                         F ull term -- of full term preg
                                4
                         P re mature -- of premature preg
                                1
                         A bortion - of aborted pregnancies
                                2
                         L ive - of living children
                                4

                    If mother had twins
                          G 7P5 (4-1-2-5)
                                Number of pregnancies remained the same
                                If first pregnancy is twin, count it as one
                                       If both were delivered, count both as one

Systems Review
         o Aks ROS -- review of symptoms
         o Where you ask questions that's not asked in HPI (history of present
         o Under the symptoms not pertaining to particular system
                   Fever, chills, malaise, fatiguability, weight change
                            + or - (Meron o Wala?)
                   Integumentary
                            Pigmentation or texture change, pruritus, scaly skin,
                               changes in the consistency
         o Head and neck
                   Head injuries, syncope, blurring, eye pain, ear pain, tennitus
                      (ringing sensation that you hear), vertigo (change in sense of
                      smell), epistaxis (nose bleeding), disturbance of taste
         o Respiratory
                   Dyspnea, chest pain, cough, back pain
                   Patient experience chest pain due to heart? Lungs?
                            On deep breathing, movement of chest, place chest pain
                               under respiratory
                            Felt when patient is exhausted --place pain under cardio
                               -- anginal
         o Cardiovascular
                   Palpitation -- skip beat, very slow, very fast, aware conscious
                      about the beating of the heart , but usually not, thought
                      difficulty of breathing due to asthma -- really heart related
                   Easy fatiguability, shortness of breath
         o GIT
                   Problem with appetite, diarrhea, constipation, flatulence,
                      steatorrhea (pale stool), melena (black stool), hematamesis
                         (vomitting of blood), hematochezia (bleeding thru the anus,
                         pussing out blood)
              o   Genito Urinary
                      Dysuria (burning sensatin while urinating), have to specify - is
                         burning sensation felt at beginning, middle, or after urination?
                      Honeymoon systitis
                      Dribbling (have to exert effort; do valsava just to initiate the
                         voiding of urine)
                              Obstruction -- benign prostatic ethropy
                      Incontinence -
                              When you cough, urine comes out
                      Hematuria
                              Tea colored urine
                      Polyuria
                              Increased volume of urination; taken so much water;
                                cold weather
                      Oliguria
                              Dec amt of urine
              o   Musculoskeletal
                      Pain, joint pain, swelling
                      Bone deformity, weakness, atrophy, restriction of motion
                      Ask about the P Q R S T
              o   Neurosystem
                      May not be relevant or included
                      Syncope (feeling that you're about to pass out)
                      Loss of memory
              o   Endocrine
                      Easy bruisability, easy
                      Ask about weight change, goiter (heat./cold intoleracne
                      Polyuria, polydypsia, polyphagia, abnormal growth

1st part
              o   symptoms
2nd part
              o   When you determine finding ----signs

Physical Exam Portion
      General survey
                 Evaluate patient on mere inspection
                 See pt for first time in clinic; patient comes to you; see how he
                   walks and you can say pt is conscious; once he talks to you,
                   there will be answers; if they are appropriate, then you say pt.
                   is coherent; see patient and assess nutritional status (anorexic,
                   thin, obese), belly exceeds boundaries of the thorax; check the
                   waist line; for women, should not go beyond 30 inches (central
                   obesity); for males (35 inches)

                        Can't bring weighing scale; done in own clinic or if pt is in
Vital signs
                 Developmental status
             Check for any mental abnormality/retardation; growth
                   Short for his age? Elongated arms? Abnormal growth?
                     Abnormal shape of the head
           Patient walk without any support? Any stability
                   Ambulatory, brought in ER on a wheelchair? Stretcher?
                          Wheelchair/stretcher born
                          Carried by relatives?
    Cardiopulmonary status
           Patient hold chest, chest pains
           Dyspnic -- rapid breathing, flaring nostrils, patient in respi
                   If not, "not in cardiopulmonary distress:
           Blood pressure
                   Systolic not > 140
                   Diastolic not > 90
                   Minimum -- varies with age; should not go beyond 100
                     systolic and 70 diastolic
                          Some can go over 80/60 with no symptoms;
                             check if hypotension is a normal variant by
                             correlating it with pulse rate
                                  Maybe pulse rate is increased
                                  Normal heart rate 60-100
                                         Above - tachycardia
                                         Below - bradycardia
                   Low cardiac rate
                          40 per minute
                          Are they athletes
                                  Good cardiac reserve; able to maintain
                                     blood pressure even with low heart rate
           Respiratory rate
                   Have a watch with you always while checking the pulse
                          Count number of breaths per minute
                   Normal - 20 max; 14 min
                          Not aware of breathing usually
                   Tachypnic
                          Rapid, but only nervous/anxious; evaluate --
                             maybe nervous about seeing the doctor
    Thermometer
           Set it; let reading go down; wipe with alcohol; wash first
           For axilla, oral, rectal
           Rectal - most accurate
           Most accurate after breakfast
Regional exams
      -6 lectures divided into 2
      Head and neck
                   Leduyo (school physician)

              Dra. Susan Gan
              Dr. Antonio David
              Dr. Quentis Pina (neurologist)
              Doesn't include rectal exam, breast exam, heart

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