History and Physical Examination Format

history and examination format

A) HISTORY

1. General Information:

  • Name:
  • Age/Gender:
  • Address:
  • Source of history: Patient/Relative/Carer

2. Chief complaints:

  • Complaint X Duration
  • Chronological order
  • Maximum 4-5
  • Should include all major symptoms (important for making hypothesis)
  • Duration should be specific rather than time interval (e.g. 10 days instead of 1-2 weeks)
  • Chief complaints can be included in retrospect

Example:

Lower abdominal pain X 2 days
Nausea and vomiting X 1 day

3. History of Presenting Illness:

“OPQRST” for each symptoms

  • Onset (acute, insidious, chronic)
  • Provocative/Palliative and Progression
  • Quality and/or Quantity
  • Region and Radiation
  • Severity
  • Timing and Temporal relationships
  • Others:
    • Duration and Frequency
    • Any diurnal variation
    • Associated symptoms
    • Last meal and Tetanus status

Negative history:

  • Red-flag symptoms
  • Ruling out differentials
  • Probable etiology
  • Severity and complications

Treatment received for the complaint

Review of systems: may or may not be related to chief complaint – include only positive finding

Add for females

Menstrual and Obstetric History:
•    LMP
•    Duration of flow/Cycle Length
•    Clots passage, Average number of pads soaked, Dysmenorrhea
•    GxPxAxLx – mode, indication and time
•    Contraceptives

Add for pediatric patients

•    Birth history

  • Any antenatal/natal/postnatal complications
  • At birth – gestational age, mode of delivery, weight

•    Development history: Gross motor/Fine motor/Language/Social

  • Development of this __ months old child matches the chronological age in all 4 spheres of development. OR if delayed
  • Development of this __ months old child in the __ area corresponds to a chronological age of between __ to __ months.

Nutritional history

  • 24 hour dietary recall

Immunization history

  • Are immunizations up to date? If not – why?

4. Past history:

  • HTN, DM, TB or any prolonged illness (duration; treated/untreated)
  • Surgeries with indication and time
  • Hospitalizations with indication and time

5. Personal history:

  • Smoking
  • Alcohol
  • Drug abuse

Eliciting smoking and alcohol history

6. Family history:

History of 2-3 generations for similar disease or related disease, hypertension or diabetes mellitus.

7. Drug and Allergy history:

  • Prescribed drugs and other medications
  • Compliance
  • Allergies and reaction

Neonatal history taking

B) Physical Examination

General examination:

G/C – Note relevant findings and abnormalities in –

Mnemonic: ABCDEF

  • Appearance
  • Built
  • Consciousness
  • Decubitus
  • Environment
  • Facies

Vitals –

  • Temp:
  • PR:
  • RR:
  • BP:
  • SpO2:
  • CRT (if applicable)
  • Bedside GRBS (if applicable)

Pallor, Icterus, Lymphadenopathy, Clubbing, Cyanosis, Edema, Dehydration:

  • Mention positive findings
  • Characterize positive finding if applicable
  • Grade positive finding if applicable

GCS and pupils – if applicable

Local examination: Of hypothetically involved system (present in detail)

P/A:

•     Any abnormalities on inspection incl. hernia orifices and external genitalia
•     Tenderness/Guarding/Rigidity
•     Organomegaly
•     Costovertebral angle tenderness
•     Percussion – if ascites (shifting dullness/fluid thrill)
•     Bowel sounds or other added sounds
•     P/R and P/V findings (if applicable)

Chest:

•     Any abnormalities in RR, Shape, Movement or use of accessory muscles
•     Any abnormalities in tracheal position, chest expansion, vocal fremitus or tenderness
•     Hyper-resonant/Resonant/Woody dullness/Stony dullness – location
•     Vesicular/Bronchial/Broncho-vesicular – location if abnormal
•     Wheeze/Crackles/Other added sounds – location
•     Vocal resonance

CVS:

•    Any abnormalities in shape or visible pulsation
•    Apex beat – location and any abnormality
•    Left parasternal heave/thrills
•    S1 S2 – any abnormality
•    Murmur
•    Location (A, P, T or M)
•    Systolic/Diastolic
•    Grading
•    JVP and HJ reflex (if relevant clinically)

CNS:

•    Higher mental functions: note only abnormalities
•    Cranial nerves: note only abnormalities
•    Motor system: note any abnormality; grade power of relevant muscles
•    Reflexes: note any abnormality; compare and grade relevant DTR
•    Sensory: light touch, superficial pain, temperature, vibration, joint position sense, stereognosis/graphesthesia
•    Cerebellar signs: mention if any sign present
•    Signs of meningeal irritation: mention if any sign present

Skin lesions:

•    Morphology:
•    Primary: Macule/Papule/Plaque/Nodule/Abscess/Wheal/Petechia/Purpura/Telangiectasia/Cyst/Milia/Burrow
•    Secondary: Scale/Erosion/Ulcer/Fissure/Excoriation/Scar
•    Shape and configuration
•    Distribution
•    Single or Multiple
•    Color
•    Edge

Joints and Spine:

•    Look: SEAD (Swelling/Erythema/Atrophy/Deformity)
•    Feel: Skin to bones and joints – note temperature, tenderness, swellings
•    Move: Active and Passive ROM
•    Measure: Motor, Sensory and Circulation status
•    Special tests: e.g. SLRT, Scaphoid test, Talar tilt test, Tests for knee ligaments, etc.

Ear:

•     External ear
•     EAC
•     TM
•     Hearing test

Nose:

•     External nose
•     Nasal mucosa and discharge

Throat:

•     Oral cavity
•     Tonsils
•     Posterior pharyngeal wall

Eye:

•    Visual acuity
•    Orbit and adnexal structures
•    Ocular movements
•    Pupil – Size, shape, symmetry, reflex
•    Conjunctiva
•    Cornea
•    Digital tonometry

System examination: Other than that mentioned in local examination (mention only abnormal findings)

If normal – mention as following:

•    Chest: B/L NVBS, no added sounds
•    CVS: S1S2 M0
•    P/A: soft, non-tender, BS+
•    CNS: grossly intact

Characterize lymph node, lump and organomegaly:
•    Site/Size/Shape/Surface/Sounds (bruits)
•    Tenderness/Transillumination/Temperature
•    Fluctuation
•    Mobility/Margin and Edge/Multiple or single
•    Color/Consistency

Arrange findings in order of inspection, palpation, percussion and auscultation.

Provisional Diagnosis

Differential Diagnoses
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3.

Management and Advice (Including investigations)
1.
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3.
4.
5.

For details about procedure and eliciting specific history and examination: Clinical skills

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