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26 CHAPTER 2: History Taking and the Medical Record
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of lumping problems together prematurely; this may serve to obscure rather
than to clarify the diagnosis.
The Plan: For each problem, and the patient as a whole, you need to develop
a management plan. The plan for each problem has three parts: (1) plans for
testing your hypothesis, (2) therapy to be considered or given, and (3) education for the patient and family.
A plan is only as good as the diagnostic hypotheses that generated it. Our
emphasis in this text is to help you think about the information acquired
in the history and physical exam so that you can generate sound, testable
hypotheses. Once you have generated a concise differential diagnosis, you
can consult textbooks and/or search the medical literature to nd an efcient
method for testing your hypotheses.
THE ORAL PRESENTATION
The optimal oral presentation holds your listener’s attention for 5 to 7 minutes
while you identify your patient and briey summarize the case. Summarize
the history, review the vital signs, pertinent physical ndings and lab results,
state the problems and diagnostic hypotheses, and then recommend a diagnostic and therapeutic plan. Excellent presentations require that you edit and
organize the information, to tell the story of the illness as it appears to you. If
you regurgitate all of the extensive information that you place in the medical
record, you will quickly lose your audience.
The oral presentation is not simply an academic exercise. Brief, accurate
presentations benet patients by clearly communicating their problems to
other participants in their care, including nurses, your teachers, fellow house
ofcers, sign-out partners in practice, and consultants.
OTHER CLINICAL NOTES
Inpatient Progress Notes: Progress notes are made daily and additionally
whenever necessary. Each note should be dated and the time of day recorded.
Each note has four subheads. Use the mnemonic SOAP to remember them:
Subjective data (symptoms and changes in symptoms, their appearance
and disappearance, and their response to therapy); Objective data (changes
in or new physical signs and laboratory ndings and response to therapy);
Assessments (updates to your problem list and hypotheses); and Plans (diagnostic tests, therapeutic interventions, and instructions to the patient and
nursing staff). When a problem is resolved by inclusion in another diagnosis,
or by cure or disappearance, it should be so noted in the progress note and in
the working problem list. The full and legible name of the writer is appended
to each progress note.
Discharge Summary: When the patient leaves the hospital, a discharge sum-
mary is created containing the principal diagnosis and all problems addressed
during the hospitalization, an abstract of the history and hospital course,
future plans, and each medication by dose and schedule, noting new, discontinued, or changed medications. Note the patient’s condition and functional
status at discharge and any information or instructions given to the patient
and attendants for home and follow-up care.
Other Clinical Notes 27
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Clinic Notes: Clinic notes follow the same SOAP format described for progress
notes in the hospital. If the chart contains standardized forms as part of the
medical record, the note may refer to those forms to avoid repetition. Clinic
notes should state the expected response to therapy, when that response is
anticipated and when the patient is to be seen in follow-up.
CHAPTER 3
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Physical Examination
A systematic history and physical exam is the foundation of the diagnostic
process. Likewise, the screening physical exam is foundational to the clinician–patient relationship. Laying on of hands is symbolic of the trusting,
respectful relationship between clinician and patient necessary for good care.
The hands-on physical examination by an experienced clinician is frequently
undervalued.
The exam imprints an image of the person in their nonidealized normal state while screening for signs of unsuspected disease or developmental
abnormalities. All four senses are used during the physical exam: inspec-
tion uses sight and smell, palpation is systematic touch and feel, percussion
uses hearing and feel, and auscultation uses hearing. Each physical exam is
an opportunity to further train these senses. Deliberate practice, study, and
experience improve the ability to detect structural and functional changes
overlooked by inexperienced examiners. Skill is achieved by routinely comparing exam ndings to laboratory and imaging studies. If discrepancies
are observed, repeat the exam. Experts have rened their senses and skills
through repetition and reection and learned from experience.
METHODS FOR PHYSICAL EXAMINATION
Inspection: Observation using sight and smell is both simple and difcult.
Simple because sight and smell are continuous during wakefulness; hard
because learning to see actively, rather than passively, is a skill acquired by
deliberate practice. Attention is unconsciously selective so that what we see
and consciously remember is biased toward what is expected and known.
The ability to see the unexpected or unknown is acquired by deliberate prac-
tice, not just by doing many exams; remember, sight is a faculty, seeing is an
art. Consequently, inspection depends entirely on the observer’s knowledge,
expectations, and training. This is epitomized in maxims such as “We see
what’s behind the eyes” (Wintrobe), “The examination does not wait the
removal of the shirt” (Waring), and “Was Man Weiss, Man sieht” (Goethe:
“What one knows, one sees”). The layperson sees someone who looks peculiar. The expert physician sees enlarged supraorbital ridges, widely spaced
teeth, large tongue, and wide hands and feet; he sees acromegaly.
Smells are impossible to describe, only experience provides a context for
interpretation. The body odors of poor hygiene, the fetor of advanced liver disease, the putrid smell of anaerobic infections, the smell of alcohol or acetone on
the breath, and many others are useful diagnostic clues to a trained observer.
General visual inspection.
whole person at rst contact. If possible, watch how the patient walks into
The physical exam begins by inspecting the
28
Methods for Physical Examination 29
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the exam room. Note how he is dressed and groomed, whether eye contact
is established, the tone and pattern of speech, how he moves and changes
position, his facial expression, skin type, overall body form and proportions,
deformities or asymmetry of face, limbs, or trunk, nutrition, specic behaviors, presence of tremor, and signs of pain. Bear in mind that the patient will
be inspecting you at the same time.
Close visual inspection.
anatomic region; the closer you look, the more you see. The art is in seeing all
that is there and distinguishing what is important from what is not. Proper
inspection requires uniform white light to avoid color distortion. Use a handheld lens, otoscope, or ophthalmoscope for magnication. Oblique lighting
emphasizes subtle changes in surface contours and motion that may be invisible with direct lighting, e.g., the apical impulse on the chest.
Olfactory inspection—smell.
required to properly identify even common odors. Odors on the breath may
indicate acetone or alcohol. Foul-smelling sputum suggests bronchiectasis or
lung abscess. Stomach contents may emit the odors of alcohol, phenol, or other
poisons, or the sour smell of fermenting food. A fecal odor may indicate intestinal obstruction. Particularly foul-smelling stool is common in pancreatic insufciency. An ammonia odor in the urine suggests fermentation in the bladder.
Pus with a nauseatingly sweet odor, like the smell of rotting apples, is indicative of gas gangrene while a fecal odor is typical of anaerobic infection.
Palpation: The hands are incredibly sensitive to a variety of stimuli: tactile,
thermal, and the kinesthetic senses of position and vibration. All normal
persons possess these senses, but training and practice are required to hone
their use as diagnostic tools, just as a blind person practices using braille to
acquire reading prociency. The ngertips are most sensitive for ne tactile dis-
crimination such as shape, surface regularity, crepitus, texture, movement, and
moisture. The thin skin on the back of the hand and ngers can detect subtle
temperature differences. Bone is more sensitive to vibration than the ngertips. To
probe for thrills and especially fremitus, rather than use the ngertips, press
the palmar aspects of the metacarpophalangeal joints or the ulnar side of the
hand (fth metacarpal and fth phalanges) to the surface. Test this for yourself
by touching a vibrating tuning fork to a ngertip and then to the base of the
nger on the palm.
Close or focused inspection concentrates on a single
Odors provide valuable clues; experience is
Specic qualities elicited by palpation
Texture. Note the surface characteristics of the skin and hair. Are they brittle,
coarse, thick, thin, roughened, or smooth?
Moisture. Assess the moisture content of the skin, hair, and mucous membranes. Are they moist and supple or dry and cracked?
Skin temperature. Palpate the head, face, trunk, arms, hands, legs, and feet
assessing the local skin temperature and the distribution of heat.
Characteristics of masses. When a mass or enlarged organ is discovered, record its size, shape, consistency, mobility, surface regularity, and the presence
or absence of expansile or transmitted pulsation.
30 CHAPTER 3: Physical Examination
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Precordial cardiac thrust. Palpate the precordium for signs of heart action.
Crepitus.
pleura, and subcutaneous tissue.
Tenderness.
over major organs. How much pressure is required to induce the uncomfortable sensation?
Thrills.
arteries, palpate them for thrills.
Vocal fremitus.
important information about the underlying pleura and lung.
Sensitive parts of the hand
Tactile sense. The ngertips are the most sensitive for ne tactile discrimination.
Temperature sense.
thinner than elsewhere on the hand.
Vibratory sense.
metacarpophalangeal joints or the ulnar side of the hand (fth metacarpal
and fth phalanges) rather than with the ngertips. Test this for yourself by
touching rst the ngertip and then the palmar base of your nger with a
vibrating tuning fork.
Sense of position and consistency.
sensations from your joints and muscles.
Methods of palpation
Light palpation. Always begin palpation with a light touch. Your sense of
touch is most acute when lightly applied, and the patient is put at ease. Gently sliding the ngertips over the skin surface may detect subtle or mobile
masses missed by forceful palpation. This also locates tender areas for later
examination.
Feel for crepitation when examining bones, joints, tendon sheaths,
Note discomfort or pain on palpation of accessible tissues and
Palpate the precordium for thrills. If bruits are heard in the major
Palpating vocal vibrations through the chest wall provides
Use the dorsa of the hands or ngers; the skin is much
Palpate to detect vibrations with the palmar aspects of the
Use the grasping ngers perceiving with
Deep palpation. Firm pressure displaces supercial tissues allowing pal-
pation for deeper structures. Though especially useful in the abdomen,
deep palpation is also used in the neck, breasts, and large muscle masses.
Whenever possible, avoid rm palpation over nerves and other tender
structures.
Bimanual palpation. The tissue is examined between the ngers of both
hands. It is useful for abdominal, pelvic, muscle, and joint examinations and
soft tissues such as breasts and intraoral structures.
Percussion: In percussion the body surface is struck generating a sound wave
that vibrates the underlying tissues producing percussion notes of frequencies that vary with the density of the tissues and structures being percussed.
Methods for Physical Examination 31
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FIG. 3-1Method of Indirect (Bimanual) Percussion. The terminal digit of the left long finger is firmly applied to
an inter space, or other body surf ace, as a pleximeter. The distal interphalangeal joint of that finger is struck a sharp blow with
the tip of the flexed right long finger. To furnish blows of equal intensity, the fingers of the right hand are held partly flexed
and the wrist is loose so that t he striking hand pivots exclusively at the relaxed wrist. To avoid dampening the vibrations after
striking the blow, withdraw the plexor hand rapidly from the pleximeter.
Bimanual, mediate, or indirect method of percussion. The tool used to
strike is a pleximeter. The body surface is struck directly or an object, a plexor,
applied to the body surface is struck. The latter is indirect or mediate percussion.
Most commonly, the distal phalanx of the nondominant long nger is rmly
pressed onto the body surface and struck by the partly exed and rigid dominant long ngertip by bending the wrist, the hand’s momentum ensuring
repetitive blows of equal force (Fig. 3-1). The wrist is relaxed and neither the
elbow nor the shoulder move. To avoid damping the vibrations, the plexor
must rebound quickly from the pleximeter. To compare notes at two sites, two
or three staccato blows are struck in one place before moving the pleximeter
to percuss the second site. Reex hammers are excellent easy to use plexors.
Direct percussion.
Striking the body surface directly by a nger, hand, or
reex hammer is direct or immediate percussion. Be careful not to strike too rmly.
Sonorous percussion.
Percussing a low-density air-lled lung produces one
sound while a dense uid-lled lung produces quite another. This principle is
used to estimate the density of the lungs, pleura, pleural space, and abdominal viscera. In the chest, it requires a blow strong enough to vibrate tissue to
a radius of 6 cm. The sounds correlating with different densities have specic
names. Percussing air in the stomach yields tympany. The note from air-lled
normal lung, lled with small air sacs and septa, has a different pitch and timbre termed resonance. Percussing over emphysematous lung produces hyper-
resonance, intermediate between resonance and tympany. Dullness is elicited
by percussion over the heart when not covered by inated lung. The note
from percussion of the thigh muscles is atness. Language cannot describe
these sounds and attempts to do so are futile and confusing. The sounds’
pitch and timbre are learned by listening. In a nontechnical sense, the percussion sounds are notes on a scale progressing from high-density tissues to
those of low-density in the sequence at, dull, resonant, hyperresonant, and
tympanitic. The duration of sound varies inversely with the density. Flatness
is very short, and, as the density decreases, each succeeding note is longer.
With practice, changes in resonance can be felt by lightly placing the index
and ring nger on either side of the middle nger plexor.
32 CHAPTER 3: Physical Examination
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Denitive percussion. When the density of an organ is invariable and different from the surrounding tissue’s density, the organ’s borders are at the
transition point from one sound to the other; this is denitive percussion. For
example, normally, the lateral heart border can be identied by percussion
where it lies against air-lled lung. Strike a lighter blow for denitive percussion than for sonorous percussion. Estimate an organ’s size by mapping the
density boundary. Denitive percussion locates the lung bases, diaphragm
movement, a pleural uid level, mediastinal width, heart size, the size and
shape of the liver and spleen, and the size of a distended gallbladder or urinary bladder. Caveat: denitive percussion is not denitive. At best it generates a hypothesis.
Auscultation: Use a stethoscope to listen to sounds arising within the body,
particularly from the lungs, heart, abdomen, and great vessels. This is auscultation. The ear can be trained to distinguish sounds quite accurately.
Each person recognizes familiar voices by rhythm and patterns of pitch and
overtones. Similarly, with deliberate practice, auscultatory skill is developed
as initial impressions are compared to ndings from investigations testing
the examiner’s hypotheses, e.g., comparing the auscultatory impression of a
heart murmur to the ndings from an echocardiogram. By listening as often
as possible to known lesions of different types and severity, both the ear’s
discrimination and the examiner’s interpretations improve.
The stethoscope. The stethoscope encloses a vibrating air column connecting the body wall to the ears. All stethoscopes modify sound to some
extent, so use the same instrument whenever possible. The basic stethoscope
excludes extraneous sounds but does not amplify sound. Electronic stethoscopes amplify, record, and project sounds making them particularly useful
for teaching. Binaural instruments have a chest piece, thick-walled tubing,
and two earpieces connected by a spring. Two chest pieces are needed to
detect the full range of frequencies. The bell’s hollow cone transmits all chest
sounds particularly the low-frequency sounds, e.g., mitral stenosis murmurs
and fetal heart sounds may only be heard with the bell. A wide bell transmits
lower-pitched sounds than a narrow-diameter bell. The diaphragm is a at
cup covered with a semirigid diaphragm that lters out low-pitched sounds
making the isolated high-pitched sounds seem louder. The diaphragm is best
suited for breath sounds and high-pitched heart sounds, e.g., aortic regurgitation. For optimal acoustics, the tubing should not exceed 30 cm. The earpiece
should close the external auditory meatus without discomfort.
Technique for Auscultation.
skin while the bell’s rim should lightly touch the skin with just enough pressure to form a seal. Heavy pressure with the bell stretches the skin creating a
diaphragm effect that excludes low pitches. Learn to ignore extraneous ambient noise. This subconscious editing can lead to missing important ndings.
To avoid this, listen actively, searching the full frequency spectrum. Breathing
on the tubing produces a recognizable noise. Skin or hair rubbing on the
chest piece produces sounds like crackles. Eliminate this by wetting the hair
or using a rubber rim on the bell. Muscle, joint, and tendon movements sound
like friction rubs; learn to recognize them. Use the bell for narrow spaces such
as the supraclavicular fossae. Keep the stethoscope clean and free of cerumen.
Regularly inspect the instrument replacing damaged parts promptly.
The diaphragm is pressed rmly against the
The Screening Physical Examination 33
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THE SCREENING PHYSICAL EXAMINATION
A screening physical exam is performed periodically for children and most
adults. The screening exam is standardized for patients of the same age and
gender. Every clinician must become procient at a structured screening
exam that will identify signicant abnormalities. The exam is sequenced for
efciency and patient comfort. Examine the body by regions. Examine regions;
think systems. This requires deliberate practice, reection, and experience.
A novice may identify all the signs but have trouble integrating those ndings into a complete anatomic and physiologic picture. This integration is
critical for generating unifying diagnostic hypotheses (see Problem Lists and
Hypothesis Generation, Chapter 1 pages 5-6). Abnormalities encountered
focus attention on possible anatomic or physiologic problems needing more
detailed evaluation, including a detailed diagnostic exam.
Efciency requires a well-organized exam room with easily accessible
instruments familiar to the examiner. Examining each patient from head to
foot in the same sequence avoids missing signs and develops an appreciation
of normal variations. Avoid excessive changes of position by the examiner
or patient. Each change takes time and may be uncomfortable for both. The
screening exam outlined below can be performed in 15 minutes or less. Keep
the following points in mind:
1. Respect the patient’s modesty.
2. Maintain professional demeanor throughout.
3. Performed properly and professionally, the screening exam supports a
professional relationship and reassures the patient.
Preparing the Screening Examination: This multisystem screening exam is
performed with the patient in four or ve positions (Fig. 3-2). It should take
no more than 15 minutes to complete. The following sections describe the
exam sequence. The methods for each regional examination are detailed in
their respective chapters.
Preparation
Equipment. The following equipment must be easily accessible: stethoscope,
sphygmomanometer, otoscope, ophthalmoscope, penlight, tongue blades,
reex hammer, tuning fork, calibrated monolament, tape measure, gloves,
lubricant, sterile swabs, and materials for specimen collection during the female pelvic exam. Wear gloves when examining the anus, rectum, genitalia,
infected skin, oral cavity, and when contact with body uids may occur.
Patient. The patient undresses in private, puts on a gown, and sits on the end
of the exam table with a sheet draped over the lap and the legs.
Clinician. The clinician must be modestly and neatly dressed. To assure privacy and avoid problems, always leave the room while the patient prepares
for the exam. If the patient requires assistance, ask a nurse or family member to
assist. Always address patients as Mr., Mrs., Miss or Ms. and by his or her last
name, unless otherwise directed by the patient. The clinician must be comfortable with the form of address; excessive informality may lead to problems. As
you proceed, keep the patient informed about the plan and sequence of the
examination so they can anticipate the next steps. Always have a chaperone
34 CHAPTER 3: Physical Examination
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A.
C.
FIG. 3-2The Office Screening Physical Examination. A. Patient draped and seated (physician facing). B. Patient
draped and seated (physician to right and back). C. Patient draped and supine (physician to right). The patient placed in the
left lateral decubitus position to listen at the cardiac apex. D. Female pelvic exam: patient draped and supine, knees and hips
flexed (physician at foot).
B.
D.
present for opposite gender genital and female breast exams; avoid delays by
alerting staff of the need for their presence before entering the room. Preserve
and protect the patient’s modesty keeping genitalia and female breasts
covered
when not being directly examined. Always observe rst without comment and
control facial and body language throughout the exam. Remember, patients
observe clinicians as closely as clinicians observe patients. Be sure communications, both verbal and nonverbal, convey professionalism and inspire
condence.
Performing the Screening Examination
Phase A. Vital signs; inspection, general and close; palpation of the head,
ears, eyes, nose, and throat.
Patient and examiner positions. The patient is seated on the exam table,
draped and facing the examiner.
The clinician cleans their hands in view of the patient.
Vital signs. Obtain the vital signs or, if previously obtained, review them
rechecking abnormal ndings.
The Screening Physical Examination 35
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General inspection. Note the patient’s general appearance. Inspect the head
and face, sclera and conjunctivae, external ears, scalp, skin of the head and
neck, the hands and ngernails, and the skin of the arms. To expose the scalp,
brush hair back moving against the grain.
Close inspection.
sual elds by confrontation, elicit extraocular movements, observe pupil size
and reactions, examine the fundi, and inspect the oral cavity and oropharynx using a tongue blade to expose the posterior pharynx, lateral tongue,
and gums.
Palpation.
gloved bimanual palpation for intraoral lesions. Palpate any hand, wrist, and
elbow joint deformity for synovitis or effusion. Palpate all skin rashes.
Phase B. Inspection of the back of the head, neck, back, and shoulders; palpation of the neck, shoulders, and back; percussion of the spine and lungs;
auscultation of the lungs.
Patient and examiner positions. Patient seated and draped; examiner stands
and/or sits on the exam table behind and to the patient’s right.
Inspection.
from back and side; check range of neck motion.
Palpation.
position of the trachea; search each lymph node bed for adenopathy; identify
the thoracic and lumbar vertebral spines by inspection and palpation, note
scoliosis or excessive kyphosis or lordosis; palpate any deformity or swelling
of the neck, back, shoulders, or scapulae.
Percussion. Use direct st percussion to check for spinal or costovertebral
angle tenderness; percuss the chest front and back comparing right to left and
apices to bases; percuss in inspiration and expiration to ascertain movement
of the diaphragm.
Examine the ears with the otoscope, check hearing, test vi-
Palpate any concerning areas of head, face, or mouth using
Expose the patient’s back inspecting the skin; inspect the neck
Palpate the anterior neck noting carotid pulsations, thyroid, and
Auscultation. Auscultate the chest posteriorly, laterally, and anteriorly under
the gown, comparing right to left and apices to bases.
Phase C (female patients). The seated breast examination.
Patient and examiner position.
iner. After proper explanation, expose the breasts while the patient sits with
the arms relaxed.
Inspection. Inspect for symmetry, skin dimpling, and nipple retraction; have
the patient press her hands to her waist then raise her hands over her head,
each time repeating the inspection.
Palpation. Pendulous breasts are most easily examined bimanually in this
position.
Patient draped and seated facing the exam-
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