Transcript Anemia

History and Physical Examination
Mike Clark, M.D.
Patient Presents
• The patient comes to the physician’s office with a
problem. The clinician listens to the patient’s
problem (symptoms). The patient may also show
visually or audibly signs of the problem. From this
the clinician must figure out what the problem is
(diagnosis).
• In order to do this the clinician must first perform a
history and physical examination.
• It is as a result of the history and physical
examination that certain laboratory tests
are decided upon.
How to Take a Patient History
1. Chief Complaint (what is the reason the
patient came into the office – write down
preferably in the patient’s own words)
2. History of Present Illness – This is where a
more complete description of why the
patient presented. It will include everything
historically (questioning of patient) that can
pertain to the chief complaint.
Example – John is a 27 year old male who
presents with ------
3. Past Medical History – ask questions to obtain a
good past medical history (medical illnesses,
surgeries, medications being taken, blood
transfusions, allergies)
4. Family History – ask questions about history of
diseases that could be genetic (diabetes,
cancers, heart disease, mental disorders,
autoimmune disorders)
5. Social History - ask questions related to living
arrangements, occupation, marital status,
number of children, drug use (including tobacco,
alcohol, other recreational drug use), recent
foreign travel, and exposure to environmental
pathogens through recreational activities or pets
6. Review of Systems - generally presented in a
questionnaire to be sure every system
historically has been investigated.
(See example of form)
Physical Examination
In a physical examination – all that can be done
is
• Visualization – observe the patient
• Palpation – feel areas of the patient
• Percussion – a thumping action to identify
organ borders
• Auscultation – listen to patient sounds
Physical Examination
1. Vital Signs and Biometrics ( Height, Weight, Temperature,
Blood Pressure, Pulse, Respiratory Rate)
Note: How much detail you go into during the physical exam
depends on the specialty.
2. HEENT – head, ears, eyes, nose and throat
3. Lungs – checking for breath sounds – expansion of the
chest and other findings
4. Heart- sounds, heaves, thrusts, PMI
5. Abdomen – intestinal sounds, pain, lumps and other
findings
6. Extremities – pulses and other findings
7. Neurological – reflexes, cranial nerves and other findings
8. Gynecologic
9. Psychiatric
Impression / Differential Diagnosis
As a result of the findings in the patient
history combined with the findings in the
physical examination – the clinician compiles a
list of possibilities of what he/she thinks the
condition that brought the patient in may be.
Additionally, the clinician lists all the
conditions patient is already known to have.
Plan
• The plan is the action to be taken. Part of the
plan in involves the R/O process (Rule Out).
This is the process where the clinician orders
certain directed laboratory tests in order to
confirm or rule out disease possibilities on
his/her differential diagnosis list.
• The other plan involves treatment for
conditions that have been confirmed.