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C H A P T E R
The techniques of physical examination and history taking that you are about to learn embody time-honored skills of healing and patient care. Your abil- ity to gather a sensitive and nuanced history and to perform a thorough and accurate examination deepens your patient relationships, focuses your patient assessment, and sets the direction of your clinical thinking. The quality of your history and physical examination governs your next steps with the patient and guides your choices from the initially bewildering array of secondary testing and technology. Over the course of becoming an accomplished clinician, you will polish these important relational and clinical skills for a lifetime. As you enter the realm of patient assessment, you begin integrating the es- sential elements of clinical care: empathic listening; the ability to interview patients of all ages, moods, and backgrounds; the techniques for examining the different body systems; and, finally, the process of clinical reasoning. Your experience with history taking and physical examination will grow and expand, and the steps of clinical reasoning will soon begin with the first moments of the patient encounter: identifying problem symptoms and abnormal find- ings; linking findings to an underlying process of pathophysiology or psycho- pathology; and establishing and testing a set of explanatory hypotheses. Work- ing through these steps will reveal the multifaceted profile of the patient before you. Paradoxically, the very skills that allow you to assess all patients also shape the image of the unique human being entrusted to your care. Clinical Assessment: The Road Ahead This chapter provides a road map to clinical proficiency in three critical areas: the health history, the physical examination, and the written record, or “write-up.” It describes the components of the health history and how to or- ganize the patient’s story; it gives an approach and overview to the physical ex- amination and suggests a sequence for ensuring patient comfort; and, finally, it provides an example of the written record, showing documentation of find- ings from a sample patient history and physical examination. By studying the subsequent chapters of the book and perfecting the skills of examination and history taking described, you will cross into the world of patient assessment— gradually at first, but then with growing satisfaction and expertise. After you work through this chapter to chart the tasks ahead, you will be directed by subsequent chapters in your journey to clinical competence. Chapter 2, Interviewing and the Health History, expands on the techniques C H A P T E R 1 ■ A N O V E R V I E W O F P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G 1
THE HEALTH HISTORY: STRUCTURE AND PURPOSES
STRUCTURE AND PURPOSES and skills of good interviewing; Chapters 3 through 16 detail techniques for examining the different body systems. Once you master the elements of the adult history and examination, you will extend and adapt these techniques to children and adolescents. Children and adolescents evolve rapidly in both temperament and physiology; therefore, the special approaches to the inter- view and examination of children at different ages are consolidated in Chap- ter 17, Assessing Children: Infancy Through Adolescence. Finally, Chapter 18, Clinical Reasoning, Assessment, and Plan, explores the clinical reasoning process and how to document your evaluation, diagnoses, and plan. From this blend of mutual trust, respect, and clinical expertise emerges the timeless re- wards of the clinical professions. As you read about successful interviewing, you will first learn the elements of the Comprehensive Health History. For adults, the comprehensive his- tory includes Identifying Data and Source of the History, Chief Complaint(s), Present Illness, Past History, Family History, Personal and Social History, and Review of Systems. As you talk with the patient, you must learn to elicit and organize all of these elements of the patient’s health. Bear in mind that dur- ing the interview this information will not spring forth in this order! How- ever, you will quickly learn to identify where to fit in the different aspects of the patient’s story. As you gain experience assessing patients in different settings, you will find that new patients in the office or in the hospital merit a comprehensive health history; however, in many situations a more flexible focused, or problem- oriented, interview may be appropriate. Like a tailor fitting a special garment, you will adapt the scope of the health history to a number of factors: the pa- tient’s concerns and problems; your goals for assessment; the clinical setting (inpatient or outpatient; specialty or primary care); and the amount of time available. Knowing the content and relevance of all components of the com- prehensive health history allows you to choose those elements that will be most helpful for addressing patient concerns in different contexts. The components of the comprehensive health history structure the patient’s story and the format of your written record, but the order shown here should not dictate the sequence of the interview. Usually the interview will be more fluid and will follow the patient’s leads and cues, as described in Chapter 2. Each segment of the history has a specific purpose, which is sum- marized below. These components of the comprehensive adult health history are more fully described in the next few pages. The comprehensive pediatric history appears in Chapter 17. These sample adult and pediatric health histories follow stan- 2 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
THE HEALTH HISTORY: STRUCTURE AND PURPOSES
Complaint(s) Illness Subjective Data Objective Data What the patient tells you What you detect on the examination The history, from chief complaint All physical examination findings through Review of Systems Example: Mrs. G is a 54 - year-old Example: Mrs. G is an older white female, hairdresser who reports pressure over deconditioned, pleasant, and cooperative. her left chest “like an elephant sitting BP 160/80, HR 96 and regular, there,” which goes into her left neck respiratory rate 24, afebrile. and arm.
Date and Time of History. The date is always important. You are
strongly advised to routinely document the time you evaluate the patient, especially in urgent, emergent, or hospital settings.
Identifying Data. Includes age, gender, marital status, and occupa-
tion. The source of history or referral can be the patient, a family member or friend, an officer, a consultant, or the medical record. Patients requesting evaluations for schools, agencies, or insurance companies may have special priorities compared to patients seeking care on their own initiative. Desig- nating the source of referral helps you to assess the type of information pro- vided and any possible biases.
Reliability. Should be documented if relevant. For example, “The patient
is vague when describing symptoms and unable to specify details.” This judg- ment reflects the quality of the information provided by the patient and is usually made at the end of the interview. Make every attempt to quote the patient’s own words. For example, “My stomach hurts and I feel awful.” Sometimes patients have no overt com- plaints, in which case you should report their goals instead. For example, “I have come for my regular checkup”; or “I’ve been admitted for a thorough evaluation of my heart.” This section of the history is a complete, clear, and chronologic account of the problems prompting the patient to seek care. The narrative should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatments. The principal symptoms should be well-characterized, with descriptions of (1) location, (2) quality, (3) quantity or severity, (4) tim- ing, including onset, duration, and frequency, (5) the setting in which they occur, (6) factors that have aggravated or relieved the symptoms, and (7) as- 4 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
THE HEALTH HISTORY: STRUCTURE AND PURPOSES
History sociated manifestations. These seven attributes are invaluable for under- standing all patient symptoms (see p. ). It is also important to include “pertinent positives” and “pertinent negatives” from sections of the Review of Systems related to the Chief Complaint(s). These designate the presence or absence of symptoms relevant to the differential diagnosis, which refers to the most likely diagnoses explaining the patient’s condition. Other informa- tion is frequently relevant, such as risk factors for coronary artery disease in pa- tients with chest pain, or current medications in patients with syncope. The pre- sent illness should reveal the patient’s responses to his or her symptoms and what effect the illness has had on the patient’s life. Always remember, the data flows spontaneously from the patient, but the task of organization is yours. Medications should be noted, including name, dose, route, and frequency of use. Also list home remedies, nonprescription drugs, vitamins, mineral or herbal supplements, birth control pills, and medicines borrowed from family members or friends. It is a good idea to ask patients to bring in all of their med- ications so you can see exactly what they take. Allergies, including specific re- actions to each medication, such as rash or nausea, must be recorded, as well as allergies to foods, insects, or environmental factors. Note tobacco use, includ- ing the type used. Cigarettes are often reported in pack-years (a person who has smoked 11 ⁄ 2 packs a day for 12 years has an 18 - pack-year history). If some- one has quit, note for how long. Alcohol and drug use should always be queried (see p. for suggested questions). (Note that tobacco, alcohol, and drugs may also be included in the Personal and Social History; however, many clinicians find these habits pertinent to the Present Illness.) Past History Childhood illnesses, such as measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, scarlet fever, and polio are included in the Past History. Also included are any chronic childhood illnesses. You should pro- vide information relative to Adult Illnesses in each of four areas: Medical (such as diabetes, hypertension, hepatitis, asthma, HIV disease, information about hospitalizations, number and gender of partners, at-risk sexual practices); sur- gical (include dates, indications, and types of operations); Obstetric/gynecologic (relate obstetric history, menstrual history, birth control, and sexual function); and Psychiatric (include dates, diagnoses, hospitalizations, and treatments). You should also cover selected aspects of Health Maintenance, including Im- munizations, such as tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, hepatitis B, Haemophilus influenza type b, and pneumo- coccal vaccines (these can usually be obtained from prior medical records), and Screening Tests, such as tuberculin tests, Pap smears, mammograms, stools for occult blood, and cholesterol tests, together with the results and the dates they were last performed. If the patient does not know this information, writ- ten permission may be needed to obtain old medical records. Under Family History, outline or diagram the age and health, or age and cause of death, of each immediate relative, including parents, grandparents, sib- C H A P T E R 1 ■ A N O V E R V I E W O F P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G 5
THE HEALTH HISTORY: STRUCTURE AND PURPOSES
“How about your bowels?” Note that you will vary the need for additional questions depending on the patient’s age, complaints, general state of health, and your clinical judgment. The Review of Systems questions may uncover problems that the patient has overlooked, particularly in areas unrelated to the present illness. Significant health events, such as a major prior illness or a parent’s death, require full exploration. Remember that major health events should be moved to the present illness or past history in your write-up. Keep your technique flexible. Inter- viewing the patient yields a variety of information that you organize into for- mal written format only after the interview and examination are completed. Some clinicians do the Review of Systems during the physical examination, asking about the ears, for example, as they examine them. If the patient has only a few symptoms, this combination can be efficient. However, if there are multiple symptoms, the flow of both the history and the examination can be disrupted and necessary note-taking becomes awkward. Listed below is a standard series of review-of-system questions. As you gain experience, the “yes or no” questions, placed at the end of the interview, will take no more than several minutes. General. Usual weight, recent weight change, any clothes that fit more tightly or loosely than before. Weakness, fatigue, fever. Skin. Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails. Head, Eyes, Ears, Nose, Throat (HEENT). Head: Headache, head in- jury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, ver- tigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness. Neck. Lumps, “swollen glands,” goiter, pain, or stiffness in the neck. Breasts. Lumps, pain or discomfort, nipple discharge, self-examination practices. Respiratory. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bron- chitis, emphysema, pneumonia, and tuberculosis. Cardiovascular. Heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, C H A P T E R 1 ■ A N O V E R V I E W O F P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G 7
THE HEALTH HISTORY: STRUCTURE AND PURPOSES
paroxysmal nocturnal dyspnea, edema, past electrocardiographic or other heart test results. Gastrointestinal. Trouble swallowing, heartburn, appetite, nausea, bowel movements, color and size of stools, change in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Ab- dominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis. Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, inconti- nence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. Genital. Male: Hernias, discharge from or sores on the penis, testicu- lar pain or masses, history of sexually transmitted diseases and their treat- ments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Exposure to HIV infection. Female: Age at menarche; regularity, frequency, and duration of periods; amount of bleed- ing, bleeding between periods or after intercourse, last menstrual period; dysmenorrhea, premenstrual tension; age at menopause, menopausal symp- toms, postmenopausal bleeding. If the patient was born before 1971, expo- sure to diethylstilbestrol (DES) from maternal use during pregnancy. Vagi- nal discharge, itching, sores, lumps, sexually transmitted diseases and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced); complications of pregnancy; birth control methods. Sexual preference, interest, function, satisfaction, any prob- lems, including dyspareunia. Exposure to HIV infection. Peripheral Vascular. Intermittent claudication, leg cramps, varicose veins, past clots in the veins. Musculoskeletal. Muscle or joint pains, stiffness, arthritis, gout, and backache. If present, describe location of affected joints or muscles, presence of any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (for example, morning or evening), duration, and any history of trauma. Neurologic. Fainting, blackouts, seizures, weakness, paralysis, numb- ness or loss of sensation, tingling or “pins and needles,” tremors or other in- voluntary movements. Hematologic. Anemia, easy bruising or bleeding, past transfusions and/or transfusion reactions. Endocrine. Thyroid trouble, heat or cold intolerance, excessive sweat- ing, excessive thirst or hunger, polyuria, change in glove or shoe size. Psychiatric. Nervousness, tension, mood, including depression, mem- ory change, suicide attempts, if relevant. 8 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
THE PHYSICAL EXAMINATION: APPROACH AND OVERVIEW
musculoskeletal system and the nervous system. Some of these options are in- dicated below. With practice, you will develop your own sequence, keeping the need for thoroughness and patient comfort in mind. After you complete your study and practice the techniques described in the regional examina- tion chapters, reread this overview to see how each segment of the exami- nation fits into an integrated whole. The Comprehensive Physical Examination
General Survey. Observe the patient’s general state of health, height,
build, and sexual development. Obtain the patient’s weight. Note posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of the body or breath. Watch the patient’s facial expressions and note manner, affect, and reactions to persons and things in the environment. Lis- ten to the patient’s manner of speaking and note the state of awareness or level of consciousness.
Vital Signs. Measure height and weight. Measure the blood pressure.
Count the pulse and respiratory rate. If indicated, measure the body tem- perature.
Skin. Observe the skin of the face and its characteristics. Identify any
lesions, noting their location, distribution, arrangement, type, and color. Inspect and palpate the hair and nails. Study the patient’s hands. Continue your assessment of the skin as you examine the other body regions.
Head, Eyes, Ears, Nose, Throat (HEENT ). Head: Examine the hair,
scalp, skull, and face. Eyes: Check visual acuity and screen the visual fields. Note the position and alignment of the eyes. Observe the eyelids and inspect the sclera and conjunctiva of each eye. With oblique lighting, inspect each cornea, iris, and lens. Compare the pupils, and test their reactions to light. Assess the extraocular movements. With an ophthalmoscope, inspect the oc- ular fundi. Ears: Inspect the auricles, canals, and drums. Check auditory acu- ity. If acuity is diminished, check lateralization (Weber test) and compare air and bone conduction (Rinne test). Nose and sinuses: Examine the external nose; using a light and a nasal speculum, inspect the nasal mucosa, septum, and turbinates. Palpate for tenderness of the frontal and maxillary sinuses. Throat (or mouth and pharynx): Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx. (You may wish to assess the cranial nerves during this portion of the examination.)
Neck. Inspect and palpate the cervical lymph nodes. Note any masses or
unusual pulsations in the neck. Feel for any deviation of the trachea. Ob- serve sound and effort of the patient’s breathing. Inspect and palpate the thyroid gland.
Back. Inspect and palpate the spine and muscles of the back.
The survey continues throughout the history and examination. The patient is sitting on the edge of the bed or examining table, unless this position is contra- indicated. You should be standing in front of the patient, moving to either side as needed. The room should be darkened for the ophthalmoscopic examination. This promotes papillary dilation and visibility of the fundi. Move behind the sitting patient to feel the thyroid gland and to examine the back, posterior thorax, and the lungs. 10 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
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Posterior Thorax and Lungs. Inspect and palpate the spine and mus-
cles of the upper back. Inspect, palpate, and percuss the chest. Identify the level of diaphragmatic dullness on each side. Listen to the breath sounds; identify any adventitious (or added) sounds, and, if indicated, listen to the transmitted voice sounds (see p. ).
Breasts, Axillae, and Epitrochlear Nodes. In a woman, inspect the
breasts with her arms relaxed, then elevated, and then with her hands pressed on her hips. In either sex, inspect the axillae and feel for the axillary nodes. Feel for the epitrochlear nodes. A Note on the Musculoskeletal System: By this time, you have made some preliminary observations of the musculoskeletal system. You have inspected the hands, surveyed the upper back, and at least in women, made a fair es- timate of the shoulders’ range of motion. Use these and subsequent obser- vations to decide whether a full musculoskeletal examination is warranted. If indicated, with the patient still sitting, examine the hands, arms, shoulders, neck, and temporomandibular joints. Inspect and palpate the joints and check their range of motion. ( You may choose to examine upper extremity muscle bulk, tone, strength, and reflexes at this time, or you may decide to wait until later.) Palpate the breasts, while at the same time continuing your inspection.
Anterior Thorax and Lungs. Inspect, palpate, and percuss the chest.
Listen to the breath sounds, any adventitious sounds, and, if indicated, transmitted voice sounds.
Cardiovascular System. Observe the jugular venous pulsations, and
measure the jugular venous pressure in relation to the sternal angle. Inspect and palpate the carotid pulsations. Listen for carotid bruits. Inspect and palpate the precordium. Note the location, diameter, amplitude, and duration of the apical impulse. Listen at the apex and the lower sternal border with the bell of a stethoscope. Listen at each auscultatory area with the diaphragm. Listen for the first and second heart sounds, and for physi- ologic splitting of the second heart sound. Listen for any abnormal heart sounds or murmurs.
Abdomen. Inspect, auscultate, and percuss the abdomen. Palpate lightly,
then deeply. Assess the liver and spleen by percussion and then palpation. Try to feel the kidneys, and palpate the aorta and its pulsations. If you sus- pect kidney infection, percuss posteriorly over the costovertebral angles.
Lower Extremities. Examine the legs, assessing three systems while the
patient is still supine. Each of these three systems can be further assessed when the patient stands. The patient is still sitting. Move to the front again. The patient position is supine. Ask the patient to lie down. You should stand at the right side of the patient’s bed. Elevate the head of the bed to about 30° for the cardiovascular examination, adjusting as necessary to see the jugular venous pulsations. Ask the patient to roll partly onto the left side while you listen at the apex. Then have the patient roll back to the supine position while you listen to the rest of the heart. The patient should sit, lean forward, and exhale while you listen for the murmur of aortic regurgitation. Lower the head of the bed to the flat position. The patient should be supine. The patient is supine. C H A P T E R 1 ■ A N O V E R V I E W O F P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G 11
RECORDING YOUR FINDINGS
Reflexes. Including biceps, triceps, brachioradialis, patellar, Achilles deep tendon reflexes; also plantar reflexes or Babinski reflex (see p. ).
Additional Examinations. The rectal and genital examinations are
often performed at the end of the physical examination. Patient positioning is as indicated. Rectal Examination in Men. Inspect the sacrococcygeal and perianal areas. Palpate the anal canal, rectum, and prostate. If the patient cannot stand, examine the genitalia before doing the rectal examination. Genital and Rectal Examination in Women. Examine the external genitalia, vagina, and cervix. Obtain a Pap smear. Palpate the uterus and adnexa. Do a rectovaginal and rectal examination. The patient is lying on his left side for the rectal examination. The patient is supine in the lithot- omy position. You should be seated during examination with the speculum, then standing during bimanual examination of the uterus, adnexa, and rectum. Now you are ready to review an actual written record documenting a patient’s history and physical findings, illustrated below using the example of “Mrs. N.” The history and physical examination form the database for your subsequent assessment(s) of the patient and your plan(s) with the patient for management and next steps. Your written record organizes the information from the his- tory and physical examination and should clearly communicate the patient’s clinical issues to all members of the health care team. You will find that fol- lowing a standardized format is often the most efficient and helpful way to transfer this information. Your written record should also facilitate clinical reasoning and communi- cate essential information to the many health professionals involved in your patient’s care. Chapter 18, Clinical Reasoning, Assessment, and Plan, will provide more comprehensive information for formulating the assessment and plan, and additional guidelines for documentation. If you are a beginner, organizing the Present Illness may be especially chal- lenging, but do not get discouraged. Considerable knowledge is needed to cluster related symptoms and physical signs. If you are unfamiliar with hyper- thyroidism, for example, it may not be apparent that muscular weakness, heat intolerance, excessive sweating, diarrhea, and weight loss, all represent a Present Illness. Until your knowledge and judgment grow, the patient’s story and the seven key attributes of a symptom (see p. ) are helpful and necessary guides to what to include in this portion of the record. C H A P T E R 1 ■ A N O V E R V I E W O F P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G 13 RECORDING YOUR FINDINGS
RECORDING YOUR FINDINGS
8/30/ Mrs. N is a pleasant, 54 - year-old widowed saleswoman residing in Amarillo, Texas. Referral. None Source and Reliability. Self-referred; seems reliable. Chief Complaint: “My head aches.” Present Illness For about 3 months, Mrs. N has had increasing problems with frontal headaches. These are usually bifrontal, throbbing, and mild to moderately severe. She has missed work on several occasions due to associated nausea and vomiting. Headaches now average once a week, usually related to stress, and last 4 to 6 hours. They are relieved by sleep and putting a damp towel over the forehead. There is little relief from aspirin. No associated visual changes, motor-sensory deficits, or paresthesias. “Sick headaches” with nausea and vomiting began at age 15, recurred throughout her mid-20s, then decreased to one every 2 or 3 months and almost disappeared. The Case of Example of Mrs. N 14 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
TIPS FOR A CLEAR AND ACCURATE WRITE-UP
You should write the record as soon as possible, before the data fade from your memory. At first, you will probably prefer to take notes when talking with the pa- tient. As you gain experience, however, work toward recording the Present Illness , the Past Medical History , the Family History , the Personal and Social History , and the Review of Systems in final form during the interview. Leave spaces for filling in details later. During the physical examination , make note immediately of specific measurements, such as blood pressure and heart rate. On the other hand, record- ing multiple items interrupts the flow of the examination, and you will soon learn to remember your findings and record them after you have finished. Several key features distinguish a clear and well-organized written record. Pay special attention to the order and the degree of detail as you review the record below and later when you construct your own write-ups. Remember that if hand- written, a good record is always legible! Order of the Write-Up The order should be consistent and obvious so that future readers, including yourself, can easily find specific points of information. Keep items of history in the history, for example, and do not let them stray into the physical examination. Offset your head- ings and make them clear by using indentations and spacing to accent your organiza- tion. Create emphasis by using asterisks and underlines for important points. Arrange the present illness in chronologic order, starting with the current episode and then fill- ing in the relevant background information. If a patient with long-standing diabetes is hospitalized in a coma, for example, begin with the events leading up to the coma and then summarize the past history of the patient’s diabetes. Degree of Detail The degree of detail is also a challenge. It should be pertinent to the subject or problem but not redundant. Review the record of Mrs. N, then turn to the check- list in Chapter 18 on pp.. Decide if you think the order and detail included meet the standards of a good medical record.
RECORDING YOUR FINDINGS
or: Father died at age 43 in train accident. Mother died at age 67 of stroke; had vari- cose veins, headaches One brother, 61, with hypertension, otherwise well; one brother, 58, well except for mild arthritis; one sister, died in infancy of unknown cause Husband died at age 54 of heart attack Daughter, 33, with migraine headaches, otherwise well; son, 31, with headaches; son, 27, well No family history of diabetes, tuberculosis, heart or kidney disease, cancer, anemia, epilepsy, or mental illness. Personal and Social History Born and raised in Lake City, finished high school, married at age 19. Worked as sales clerk for 2 years, then moved with husband to Amarillo, had 3 children. Re- turned to work 15 years ago because of financial pressures. Children all married. Four years ago Mr. N died suddenly of a heart attack, leaving little savings. Mrs. N has moved to small apartment to be near daughter, Dorothy. Dorothy’s husband, Arthur, has an alcohol problem. Mrs. N’s apartment now a haven for Dorothy and her 2 children, Kevin, 6 years, and Linda, 3 years. Mrs. N feels responsible for help- ing them; feels tense and nervous but denies depression. She has friends but rarely discusses family problems: “I’d rather keep them to myself. I don’t like gos- sip.” No church or other organizational support. She is typically up at 7:00 A.M., works 9:00 to 5:30, eats dinner alone. ■ Exercise and diet. Gets little exercise. Diet high in carbohydrates. ■ Safety measures. Uses seat belt regularly. Uses sunblock. Medications kept in an unlocked medicine cabinet. Cleaning solutions in unlocked cabinet below sink. Mr. N’s shotgun and box of shells in unlocked closet upstairs. Review of Systems _General._* Has gained about 10 lb in the past 4 years. Skin. No rashes or other changes. Head, Eyes, Ears, Nose, Throat (HEENT). See Present Illness. No history of head injury. Eyes: Reading glasses for 5 years, last checked 1 year ago. No symptoms. Ears: Hearing good. No tinnitus, vertigo, infections. Nose, sinuses: Occasional mild cold. No hay fever, sinus trouble. _Throat (or mouth and pharynx):_ Some bleeding of gums recently. Last dental visit 2 years ago. Occasional canker sore. Neck. No lumps, goiter, pain. No swollen glands. Breasts. No lumps, pain, discharge. Does self-breast exam sporadically. Respiratory. No cough, wheezing, shortness of breath. Last chest x-ray, 1986, St. Mary’s Hospital; unremarkable. Cardiovascular. No known heart disease or high blood pressure; last blood pressure taken in 1998. No dyspnea, orthopnea, chest pain, palpitations. Has never had an electrocardiogram (ECG). _Gastrointestinal._* Appetite good; no nausea, vomiting, indigestion. Bowel movement about once daily, though sometimes has hard stools for 2 to 3 days when especially tense; no diarrhea or bleeding. No pain, jaundice, gallbladder or liver problems. _Urinary._* No frequency, dysuria, hematuria, or recent flank pain; nocturia 1, large volume. Occasionally loses some urine when coughs hard. 16 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
RECORDING YOUR FINDINGS
Genital. No vaginal or pelvic infections. No dyspareunia. Peripheral Vascular. Varicose veins appeared in both legs during first pregnancy. For 10 years, has had swollen ankles after prolonged standing; wears light elastic pantyhose; tried “water pill” 5 months ago, but it didn’t help much; no history of phlebitis or leg pain. Musculoskeletal. Mild, aching, low-back pain, often after a long day’s work; no ra- diation down the legs; used to do back exercises but not now. No other joint pain. Neurologic. No fainting, seizures, motor or sensory loss. Memory good. Hematologic. Except for bleeding gums, no easy bleeding. No anemia. Endocrine. No known thyroid trouble, temperature intolerance. Sweating aver- age. No symptoms or history of diabetes. Psychiatric. No history of depression or treatment for psychiatric disorders. See also Present Illness and Personal and Social History. Physical Examination Mrs. N is a short, moderately obese, middle-aged woman, who is animated and re- sponds quickly to questions. She is somewhat tense, with moist, cold hands. Her hair is fixed neatly and her clothes are immaculate. Her color is good and she lies flat without discomfort. Vital Signs. Ht (without shoes) 157 cm (5 2 ). Wt (dressed) 65 kg (143 lb). BP 164/98 right arm, supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6F. Skin. Palms cold and moist, but color good. Scattered cherry angiomas over upper trunk. Nails without clubbing, cyanosis. Head, Eyes, Ears, Nose, Throat (HEENT ). Head: Hair of average texture. Scalp with- out lesions, normocephalic/atraumatic (NC/AT). Eyes: Vision 20/30 in each eye. Visual fields full by confrontation. Conjunctiva pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally, reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhages, exudates. No arteriolar narrowing or A- V nicking. Ears: Wax partially obscures right tympanic membrane (TM); left canal clear, TM with good cone of light. Acuity good to whispered voice. Weber midline. AC > BC. Nose: Mucosa pink, septum midline. No sinus tenderness. Mouth: Oral mucosa pink. Several interdental papillae red, slightly swollen. Dentition good. Tongue midline, with 3 4 mm shallow white ulcer on red base on undersurface near tip; tender but not indurated. Tonsils absent. Pharynx without exudates. Neck. Neck supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt. Lymph Nodes. Small (<1 cm), soft, nontender, and mobile tonsillar and posterior cervical nodes bilaterally. No axillary or epitrochlear nodes. Several small inguinal nodes bilaterally, soft and nontender. Thorax and Lungs. Thorax symmetric with good excursion. Lungs resonant. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally. Cardiovascular. Jugular venous pressure 1 cm above the sternal angle, with head of examining table raised to 30. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 5th left interspace, C H A P T E R 1 ■ A N O V E R V I E W O F P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G 17
RECORDING YOUR FINDINGS
Learning History Taking and Physical Examination Now that you have surveyed the tasks ahead, the overviews of the health his- tory and physical examination, and the patient record of Mrs. N, you are ready to turn to the chapters on history taking and physical examination. Chapter 18, Clinical Reasoning, Assessment, and Plan, provides more com- prehensive information on how to formulate your Assessment and Plan, the final steps of patient assessment, and the remaining two sections of the writ- ten record. In Chapter 18 you will also find guidelines for documentation and the assessment and plan for Mrs. N. The rewards of mastering the skills of patient assessment lie just ahead! C H A P T E R 1 ■ A N O V E R V I E W O F P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G 19
RECORDING YOUR FINDINGS
