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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
