Physical Diagnosis
Diagnosing the illness
• Clinical history
The Art of History Taking
• Physical examination
• Investigations/ Diagnostic work-ups and
procedures
Kinds of History
• Good communication between the patient and
• Medical adult history: 20 y/o and above
MD
• Pediatric history: children are not little adult
• Patience, practice, understanding, and patience
o Neonatal: NB to 4 wks old
• MD: well-groom, appropriate dress
o Pediatric history: >4 wks to 9 y/o
o Adolescent history: 10 to 19 y/o • Approach to history taking: introduce yourself
and establish a rapport
Pediatric History • Be alert and pay full attention for patient is
• Informant: relation of the informant to pediatric actually telling you the diagnosis already
patient • Ensure consent has been gained; involve the
• Reliability: (in terms of %) subjective to interviewer patient in the history taking
• Personal history: • Maintain privacy and dignity
o Prenatal history • Patient should be comfortable as possible
o Natal history • Summarize each stage of the history taking
o Postnatal process
o Feeding history
o Immunization Components of History
o Growth and development - General data
• Adolescence: HEADSSS - Chief complaint
o Home - History of present illness
o Eating habits - Past medical history
o Activities - Family history
o Drugs - Socio-economic history
o Sexuality - Review of system
o Suicidal - Personal
o Strength, spirituality
GENERAL DATA
History taking • Name, sex, age, work religion, marital status,
• Process of getting information or data from residence, number of consultations/ admissions,
patient or informant date and time of consultation/ admission
• Asking specific questions that is useful in
formulating the diagnosis and providing medical CHIEF COMPLAINT
care • Reason why patient seeks medical help by
• Gathering data: patient himself, relative, visiting the physician
guardian, cohabitant, close friend • Usually a single word of symptom but
• Critical first step in determining the etiology of a occasionally of more than one complaint: fever
patient’s illness and rashes
• Let the patient describe through his own words
and be recorder
Physical Diagnosis
Catherine Gironella, MD
• Write it chronologically according to the first PAST MEDICAL HISTORY
then last symptoms noted including the duration • Any history of similar complaint in the past
• How to ask the complain • Other medical problems the patient has or had
o What brings you here? • Any chronic disease present like HPN, DM
o How can help you? • Past hospitalizations and surgeries
o What seems to be the problem? • Medications if any taken in the past (dosage and
duration)
HISTORY OF PRESENT ILLNESS • Allergies
• Elaborate on the chief complaint in detail • Trauma, fall
• Ask for relevant associated symptoms
• Lead the conversation by asking questions FAMILY HISTORY
• Always start with an open-ended question and • Genetically transmitted diseases within the
take time to the patient’s “story” family
• Once the patient has completed his narrative • Any illness that runs in the family: CVD, HPN, DM,
then closed questions can be asked to clarify CAD, Asthma
• Leading questions should be avoided • Parents and siblings with chronic illness: CRD
o Open ended questions: allow patient to • Parents if dead: cause of death and how old
express their own thoughts and feelings • e.g. sickle cells thalassemia, G-6-PD
(eg. Is there anything else that you want
to mention?) SOCIO-ECONOMIC HISTORY
o Closed question: are request for factual • Occupation, educational background, financial
information (eg. When did the pain situation
started?) • Housing water source, toilet type, garbage
o Leading questions: based on your own collection
assumptions that lead the patient to the • Diseases present around the community
answer you want to hear • Drug addiction, smoking, alcoholism: type,
• In details of present probably with time- onset/ duration, amount
mode of evolution/ any investigation/ treatment • Sexual history, STD
and outcome/ any associated (+) or (-) symptoms
• Avoid medial terminologies and make use of a SIGNS AND SYMPTOMS
descriptive language that is familiar to patients • Symptom: subjective experience that cannot be
• Sequential presentation identified by anyone, feeling of illness or mental
• Always relay story in days before admission; if change that is caused by a disease
short, in hours o Noted or placed in the Review of
• Narrate in details Systems
• Tips to gather information • Sign: objective, observable phenomenon that
o Site can be identified by the physician assessment
o Onset made by the examiner, measurable
o Character o Written in Physical Examination
o R
o A
o T
o E
o Severity
Physical Diagnosis
Catherine Gironella, MD
REVIEW OF SYSTEM: SYMPTOMS Equipment for Physical Examination
• General state: weakness, fatigue, loss of weight, • Penlight/ flashlight
night sweats • Tongue depressors
• Integumentary: itchiness, numbness, pin • Flexible tape measure
pricking • Thermometer
• Respiratory: feeling of tightness of breathing, • Watch with second hand
cough (dry or productive) • Stethoscope
• Cardiovascular: chest pain, paroxysmal • Sphygmomanometer
nocturnal dyspnea, shortness of breath, • Neurologic hammer
palpitations • Mask, gloves
• Gastrointestinal: diet, nausea, vomiting, • Diagnostic kit: ophthalmoscope/otoscope
regurgitation, heart burn, difficulty in • Tuning fork: 128 Hz, 512 Hz
swallowing, abdominal pain, change in bowel
habit
• Urinary: frequency, dysuria, urgency, hesitancy,
terminal dribbling, nocturia, back/flank pain,
incontinence, fever
• Musculoskeletal: pain at muscle, joint, bone,
swelling, weakness, limitation of
motion/movement
• Nervous: headaches, dizziness, fits/faints/black
out, loss of consciousness, muscle weakness,
numbness, loss of sensation
• Genital: pain, discomfort, itchiness, discharge,
unusual bleeding
• Sensory: blurring of vision, eye pain, flashes of
light, smell, taste, speech
At the end of the interview…
• Give summary
• Ask if patient understood the information given
• Ask if there are any other added information to
add
• Advise what your plan would be
• Check if the patient agrees with your plan
• “THANK YOU.”
