C H A P T E R
Overview of
Physical Examination
1
and History Taking
The techniques of physical examination and history taking that you are
about to learn embody time-honored skills of healing and patient care. Your
ability to gather a sensitive and nuanced history and to perform a thorough
and accurate examination deepens your relationships with patients, focuses
your assessment, and sets the direction of your clinical thinking. The qual-
ity of your history and physical examination governs your next steps with the
patient and guides your choices from among the initially bewildering array
of secondary testing and technology. Over the course of becoming an ac-
complished 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 ex-
pand, and will trigger the steps of clinical reasoning from 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.
Working 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.
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 organize
the patient’s story; it gives an approach and overview to the physical exami-
nation 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 and perfecting the skills of examination and history tak-
ing described, you will cross into the world of patient assessment—gradually
at first, but then with growing satisfaction and expertise.
CHAPTER 1 ■ OVERVIEW OF PHYSICAL EXAMINATION AND HISTORY TAKING 3
THE HEALTH HISTORY
After you study this chapter and chart the tasks ahead, subsequent chapters
will guide your journey to clinical competence.
■ Chapter 2, Interviewing and The Health History, expands on the tech-
niques and skills of good interviewing.
■ Chapter 3, Clinical Reasoning, Assessment, and Plan, explores the clinical
reasoning process and how to document your evaluation, diagnoses, and
plan for patient care.
■ Chapters 4 to 17 detail the anatomy and physiology, health history, guide-
lines for health promotion and counseling, techniques of examination,
and examples of the written record relevant to specific body systems and
regions.
■ Chapters 18 to 20 extend and adapt the elements of the adult history and
physical examination to special populations: newborns, infants, children,
and adolescents; pregnant women; and older adults.
From mastery of these skills and the mutual trust and respect of caring re-
lationships with your patients emerge the timeless rewards of the clinical
professions.
THE HEALTH HISTORY
As you read about successful interviewing, you will first learn the elements
of the Comprehensive Adult Health History. The comprehensive history in-
cludes Identifying Data and Source of the History, Chief Complaint(s), Pres-
ent 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 these elements of the patient’s health. Bear in mind that during
the interview this information will not spring forth in this order! However,
you will quickly learn to identify where to fit in the different aspects of the
patient’s story.
STRUCTURE AND PURPOSES
The Comprehensive vs. Focused Health History. As you gain ex-
perience assessing patients in different settings, you will find that new pa-
tients in the office or in the hospital merit a comprehensive health history;
however, in many situations, a more flexible focused, or problem-oriented, in-
terview may be appropriate. Like a tailor fitting a special garment, you will
adapt the scope of the health history to several factors: the patient’s concerns
and problems; your goals for assessment; the clinical setting (inpatient or
outpatient; specialty or primary care); and the time available. Knowing the
4 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
THE HEALTH HISTORY
content and relevance of all components of the comprehensive health his-
tory allows you to choose those elements that will be most helpful for ad-
dressing patient concerns in different contexts.
These components of the comprehensive adult health history are more fully
described in the next few pages. The comprehensive pediatric health history
appears in Chapter 18. These sample adult and pediatric health histories fol-
low standard formats for written documentation, which you will need to
learn. As you review these histories, you will encounter several technical
terms for symptoms. Definitions of terms, together with ways to ask about
symptoms, can be found in each of the regional examination chapters.
■ Components of the Adult Health History
Identifying Data ■ Identifying data—such as age, gender, occupation, marital
status
■ Source of the history—usually the patient, but can be family
member, friend, letter of referral, or the medical record
■ If appropriate, establish source of referral because a written
report may be needed.
Reliability Varies according to the patient’s memory, trust, and mood
Chief Complaint(s) The one or more symptoms or concerns causing the patient to
seek care
Present Illness ■ Amplifies the Chief Complaint; describes how each symptom
developed
■ Includes patient’s thoughts and feelings about the illness
■ Pulls in relevant portions of the Review of Systems (see below)
■ May include medications, allergies, habits of smoking and
alcohol, which are frequently pertinent to the present illness
Past History ■ Lists childhood illnesses
■ Lists adult illnesses with dates for at least four categories:
medical; surgical; obstetric/gynecologic; and psychiatric
■ Includes health maintenance practices such as immunizations,
screening tests, lifestyle issues, and home safety
Family History ■ Outlines or diagrams age and health, or age and cause of
death, of siblings, parents, and grandparents
■ Documents presence or absence of specific illnesses in family,
such as hypertension, coronary artery disease, etc.
Personal and Social Describes educational level, family of origin, current household,
History personal interests, and lifestyle
Review of Systems Documents presence or absence of common symptoms related
to each major body system
The components of the comprehensive health history structure the patient’s
story and the format of your written record, but the order shown 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.
Subjective vs. Objective Data. As you acquire the techniques of the
history taking and physical examination, remember the important differences
between subjective information and objective information, as summarized
CHAPTER 1 ■ OVERVIEW OF PHYSICAL EXAMINATION AND HISTORY TAKING 5
THE HEALTH HISTORY
in the accompanying table. Knowing these differences helps you apply clini-
cal reasoning and cluster patient information. These distinctions are equally
important for organizing written and oral presentations about the patient.
■ Differences Between Subjective and Objective Data
Subjective Data Objective Data
What the patient tells you What you detect during 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, overweight
hairdresser who reports pressure white female, who is pleasant and
over her left chest “like an cooperative. BP 160/80, HR 96 and
elephant sitting there,” which regular, respiratory rate 24, afebrile.
goes into her left neck and arm.
THE COMPREHENSIVE ADULT HEALTH HISTORY
Initial Information
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. These include age, gender, marital status, and occu-
pation. 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 pri-
orities compared with patients seeking care on their own initiative. Designat-
ing the source of referral helps you to assess the type of information provided
and any possible biases.
Reliability. This information should be documented if relevant. For
example, “The patient is vague when describing symptoms and cannot spec-
ify details.” This judgment reflects the quality of the information provided
by the patient and is usually made at the end of the interview.
Chief Complaint(s). Make every attempt to quote the patient’s own words.
For example, “My stomach hurts and I feel awful.” Sometimes patients have
no overt complaints, in which case you should report their goals instead. For
example, “I have come for my regular check-up”; or “I’ve been admitted for
a thorough evaluation of my heart.”
Present Illness. 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
6 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
THE HEALTH HISTORY
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) timing, including onset, duration, and frequency;
(5) the setting in which they occur; (6) factors that have aggravated or re-
lieved the symptoms; and (7) associated manifestations. These seven attri-
butes are invaluable for understanding all patient symptoms (see p. XX). 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 differ-
ential diagnosis, which refers to the most likely diagnoses explaining the pa-
tient’s condition. Other information is frequently relevant, such as risk factors
for coronary artery disease in patients with chest pain, or current medications
in patients with syncope. The Present Illness should reveal the patient’s re-
sponses to his or her symptoms and what effect the illness has had on the pa-
tient’s life. Always remember, the data flow spontaneously from the patient, but
the task of organization is yours.
Patients often have more than one complaint or concern. Each merits its
own paragraph and a full description.
Medications should be noted, including name, dose, route, and frequency of
use. Also list home remedies, nonprescription drugs, vitamins, mineral or
herbal supplements, oral contraceptives, and medicines borrowed from fam-
ily members or friends. It is a good idea to ask patients to bring in all of their
medications so you can see exactly what they take. Allergies, including specific
reactions to each medication, such as rash or nausea, must be recorded, as well
as allergies to foods, insects, or environmental factors. Note tobacco use, in-
cluding 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
someone has quit, note for how long. Alcohol and drug use should always be
investigated (see pp. XX–XX for suggested questions). (Note that tobacco, al-
cohol, and drugs may also be included in the Personal and Social History; how-
ever, many clinicians find these habits pertinent to the Present Illness.)
Past History. Childhood illnesses, such as measles, rubella, mumps, whoop-
ing cough, chickenpox, rheumatic fever, scarlet fever, and polio, are included
in the Past History. Also included are any chronic childhood illnesses.
You should provide information relative to Adult Illnesses in each of four areas:
■ Medical: Illnesses such as diabetes, hypertension, hepatitis, asthma, and
HIV; hospitalizations; number and gender of sexual partners; and risky
sexual practices
■ Surgical: Dates, indications, and types of operations
■ Obstetric/Gynecologic: Obstetric history, menstrual history, methods of
contraception, and sexual function
■ Psychiatric: Illness and time frame, diagnoses, hospitalizations, and
treatments
CHAPTER 1 ■ OVERVIEW OF PHYSICAL EXAMINATION AND HISTORY TAKING 7
THE HEALTH HISTORY
Also cover selected aspects of Health Maintenance, especially immuniza-
tions and screening tests. For immunizations, find out whether the patient
has received vaccines for tetanus, pertussis, diphtheria, polio, measles, rubella,
mumps, influenza, varicella, hepatitis B, Haemophilus influenza type B, and
pneumococci. For screening tests, review tuberculin tests, Pap smears, mam-
mograms, stool tests for occult blood, and cholesterol tests, together with
results and when they were last performed. If the patient does not know
this information, written permission may be needed to obtain old medical
records.
Family History. Under Family History, outline or diagram the age and
health, or age and cause of death, of each immediate relative, including par-
ents, grandparents, siblings, children, and grandchildren. Review each of the
following conditions and record whether they are present or absent in the
family: hypertension, coronary artery disease, elevated cholesterol levels,
stroke, diabetes, thyroid or renal disease, cancer (specify type), arthritis, tu-
berculosis, asthma or lung disease, headache, seizure disorder, mental illness,
suicide, alcohol or drug addiction, and allergies, as well as symptoms reported
by the patient.
Personal and Social History. The Personal and Social History cap-
tures the patient’s personality and interests, sources of support, coping style,
strengths, and fears. It should include occupation and the last year of school-
ing; home situation and significant others; sources of stress, both recent and
long-term; important life experiences, such as military service, job history,
financial situation, and retirement; leisure activities; religious affiliation and
spiritual beliefs; and activities of daily living (ADLs). Baseline level of func-
tion is particularly important in older or disabled patients (see p. XX for the
ADLs frequently assessed in older patients). The Personal and Social History
also conveys lifestyle habits that promote health or create risk such as exer-
cise and diet, including frequency of exercise; usual daily food intake; dietary
supplements or restrictions; use of coffee, tea, and other caffeine-containing
beverages; and safety measures, including use of seat belts, bicycle helmets,
sunblock, smoke detectors, and other devices related to specific hazards. You
may want to include any alternative health care practices.
You will come to thread personal and social questions throughout the in-
terview to make the patient feel more at ease.
Review of Systems. Understanding and using Review of Systems ques-
tions is often challenging for beginning students. Think about asking series
of questions going from “head to toe.” It is helpful to prepare the patient
for the questions to come by saying, “The next part of the history may feel
like a million questions, but they are important and I want to be thorough.”
Most Review of Systems questions pertain to symptoms, but on occasion some
clinicians also include diseases like pneumonia or tuberculosis.
If the patient remembers important illnesses as you ask questions within the
Review of Systems, record or present such illnesses as part of the Present Illness
or Past History.
8 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
THE HEALTH HISTORY
Start with a fairly general question as you address each of the different sys-
tems. This focuses the patient’s attention and allows you to shift to more
specific questions about systems that may be of concern. Examples of start-
ing questions are: “How are your ears and hearing?” “How about your lungs
and breathing?” “Any trouble with your heart?” “How is your digestion?”
“How about your bowels?” Note that you will vary the need for additional
questions depending on the patient’s age, complaints, and 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 ex-
ploration. 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, or fever.
Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes
in hair or nails; changes in size or color of moles.
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 or blurred vi-
sion, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing,
tinnitus, vertigo, 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 and gums; bleed-
ing gums; dentures, if any, and how they fit; last dental examination;
sore tongue; dry mouth; frequent sore throats; hoarseness.
Neck: “Swollen glands”; goiter; lumps, 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,
bronchitis, emphysema, pneumonia, and tuberculosis.
CHAPTER 1 ■ OVERVIEW OF PHYSICAL EXAMINATION AND HISTORY TAKING 9
THE HEALTH HISTORY
Cardiovascular: Heart trouble, high blood pressure, rheumatic fever,
heart murmurs; chest pain or discomfort; palpitations, dyspnea, or-
thopnea, paroxysmal nocturnal dyspnea, edema; results of past electro-
cardiograms or other cardiovascular tests.
Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel
movements, stool color and size, change in bowel habits, pain with
defecation, rectal bleeding or black or tarry stools, hemorrhoids, con-
stipation, diarrhea. Abdominal pain, food intolerance, excessive belch-
ing or passing of gas. Jaundice, liver, or gallbladder trouble; hepatitis.
Urinary: Frequency of urination, polyuria, nocturia, urgency, burning
or pain during urination, hematuria, urinary infections, kidney or
flank pain, kidney stones, ureteral colic, suprapubic pain, inconti-
nence; in males, reduced caliber or force of the urinary stream, hesi-
tancy, dribbling.
Genital: Male: Hernias, discharge from or sores on the penis, testicular
pain or masses, scrotal pain or swelling, history of sexually transmitted
diseases and their treatments. Sexual habits, interest, function, satis-
faction, birth control methods, condom use, and problems. Exposure
to HIV infection. Female: Age at menarche; regularity, frequency, and
duration of periods; amount of bleeding; bleeding between periods or
after intercourse; last menstrual period; dysmenorrhea; premenstrual
tension. Age at menopause, menopausal symptoms, postmenopausal
bleeding. If the patient was born before 1971, exposure to diethyl-
stilbestrol (DES) from maternal use during pregnancy (linked to cer-
vical carcinoma). Vaginal 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 problems, including dyspareunia.
Exposure to HIV infection.
Peripheral vascular: Intermittent claudication; leg cramps; varicose
veins; past clots in the veins; swelling in calves, legs, or feet; color
change in fingertips or toes during cold weather; swelling with red-
ness or tenderness.
Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, and
backache. If present, describe location of affected joints or muscles,
any swelling, redness, pain, tenderness, stiffness, weakness, or limita-
tion of motion or activity; include timing of symptoms (e.g., morn-
ing or evening), duration, and any history of trauma. Neck or low
back pain. Joint pain with systemic features such as fever, chills, rash,
anorexia, weight loss, or weakness.
Psychiatric: Nervousness; tension; mood, including depression, mem-
ory change, suicide attempts, if relevant.
10 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
THE PHYSICAL EXAMINATION
Neurologic: Changes in mood, attention, or speech; changes in orien-
tation, memory, insight, or judgment; headache, dizziness, vertigo;
fainting, blackouts, seizures, weakness, paralysis, numbness or loss of
sensation, tingling or “pins and needles,” tremors or other involun-
tary movements; seizures.
Hematologic: Anemia, easy bruising or bleeding, past transfusions,
transfusion reactions.
Endocrine: Thyroid trouble, heat or cold intolerance, excessive sweat-
ing, excessive thirst or hunger, polyuria, change in glove or shoe size.
THE PHYSICAL EXAMINATION
APPROACH AND OVERVIEW
In this section, we outline the comprehensive physical examination and pro-
vide an overview of all its components. You will conduct a comprehensive
physical examination on most new patients or patients being admitted to the
hospital. For more problem-oriented, or focused, assessments, the presenting
complaints will dictate what segments of the examination you elect to per-
form. You will find a more extended discussion of the approach to the ex-
amination, its scope (comprehensive or focused), and a table summarizing
the examination sequence in Chapter 4, Beginning the Physical Examina-
tion: General Survey and Vital Signs. Information about anatomy and phys-
iology, interview questions, techniques of examination, and important
abnormalities are detailed in Chapters 4 through 17 for each of the segments
of the physical examination described below.
For an overview of the physical examination, study the following description
of the sequence of examination now. Note that clinicians vary in where they
place different segments of the examination, especially the examinations of the
musculoskeletal system and the nervous system. Some of these options are in-
dicated below.
As you develop your own sequence of examination, an important goal is to
minimize how often you ask the patient to change position from supine to sit-
ting, or from standing to lying supine. Some suggestions for patient posi-
tioning during the different segments of the examination are indicated in the
right-hand column in red.
THE COMPREHENSIVE ADULT PHYSICAL EXAMINATION
General Survey. Observe the patient’s general state of health, height, The survey continues throughout
build, and sexual development. Obtain the patient’s weight. Note posture, the history and examination.
CHAPTER 1 ■ OVERVIEW OF PHYSICAL EXAMINATION AND HISTORY TAKING 11
