History Taking and Physical Examination (Adult)

HISTORY TAKING
GENERAL DATA
Name, Age, Date of Birth, Place of Birth, Sex, Race, Religion, Present Address, Number of Admission
Date of Admission

Informant, Relationship to the Patient, Reliability of the Informant

CHIEF COMPLAINT
Why was the patient brought to the hospital?
HISTORY OF PRESENT ILLNESS
When was the the last time you feel well?
Signs and Symptoms described in chronological order (Specific number of hours, days, weeks, or
months)

Characteristic of symptoms (SOCRATES):

Severity (Quantity), Onset (Acute or Chronic), Character (Quality), Radiation, Associated Symptoms ,
Time, Duration, Frequency, Exacerbating and Alleviating Factors, Site or Location

*Associated manifestations- fever, headache, fatigue, pain, anorexia, nausea, vomiting, cough, runny
nose (nasal congestion), bleeding, trauma, dysphagia, dyspnea, dysphonia

For weight loss: (kg) (size of pants) (significant: unintentional loss of 5% of BW in 6 months) (compare
to a coin ex. Kung piso ka sang una pila ayhan ka subong?) (ask for percentage) (ask for a picture of
the patient a year ago),

For pain (OPQRTS):

Onset
Precipitating/palliating factors (upon movement or breathing, cough, eating)
Quality (sharp, dull, burning, colicky)
Radiation (localized, referred: other quadrants, back, extremeties)
Severity (pain scale, 1–10, wong baker)
Timing (brief, fluctuating, intermittent, progressive, persistent)

For bowel changes: normal schedule, last flatus and bowel movement, size, shape, diameter (nipis),
color (yellow, black, acholic (lapsi/du abo), brown), amount (lupot, tubol, du dinuguan, ipot kanding)

For urinary changes: amount, color, dysuria, incontinence, odor

For skin lesions: type of skin lesion, color, margination, consistency, shape, arrangement, distribution

Ask if consultation was done for the presenting illness. If imaging was done, ask for specifics (location
and type).

Note medications taken (generic and brand names), actual dose, route, and duration of treatment,
home remedies done (ask for the copy of the prescription and what the drug is for ex. For pain,
antibiotics)

For chronic illnesses, state the date and age of onset

If the patient is a newborn, and the present problems are related to the prenatal and perinatal period,
note the maternal and birth history

Hyperthyroidism: palpitations, nervousness, tremors, tachycardia, proptosis, weight loss, amenorrhea

Trauma Patients:
Primary Survey (ABCDE):
Airway and cervical spine immobilization, Breathing and Ventilation, Circulation, Disabilities (GCS
score), Exposure and Events:
Secondary Survey (AMPLE):
Allergies, Medications, Past Medical History/Pregnancy, Last Meal, Events related to injuries:
Pertinent Positives (Review of Systems)

Pertinent Negatives (Review of Systems)

Review of Systems
General Weight changes, weakness, fatigue, fever
Cutaneous Changes in skin and nails
HEENT Headache, dizziness, lightheadedness, vision, redness, cataracts, hearing, ear infections,
tinnitus, vertigo, colds, stuffiness, teeth and gums,
Neck Swelling, lumps, stiffness
Breasts Lumps, pain, discharges
Respiratory Cough, dyspnea, chest pain
Cardiovascular Palpitations, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, cyanosis,
syncope
Gastrointestinal Trouble swallowing, heartburn, appetite, nausea, bowel changes, abdominal pain
Genitourinary Urinary changes, discharges, menstrual changes, sores, lumps
Musculoskeletal Muscle or joint pain, stiffness, weakness,
tenderness, limitation of motion
Neurologic Changes in mood, attention, speech, fainting, paralysis, numbness, tremors, seizures
Hematopoietic Anemia, easy bruising
Endocrine Heat and cold intolerance, excessive sweating, thirst, hunger
PAST HISTORY
A. CHILDHOOD ILLNESSES
Measles (tigdas), rubella, mumps (bayuok), whooping cough, chickenpox (sulalob), rheumatic fever,
scarlet fever, and polio
Any chronic childhood illnesses
B. ADULT ILLNESSES
Diabetes

Hypertension

Medical

Hepatitis
Asthma
HIV
Any chronic illnesses
Hospitalizations
Number and gender of sexual partners
Risk-taking sexual practices
Dates
Surgical Indications
Types of Operations
Obstetric History
(GTPAL, type(s) of delivery *if CS ask for indication, place, ultrasound results
Obstetric
(congenital anomaly scan), attending personnel, complications)
(age of 1st pregnancy, lactation/breastfeeding, infection; mastitis)
 Menstrual History
(menarche, regularity, duration, amount [no. of napkins], associated symptoms,
dysmenorrhea, vaginal discharge, LMP, bleeding bet periods)
Methods of Contraception (OCP, condoms, IUDs, injectibles)
Sexual function (bleeding after sex, pain during sex/dyspareunia, decreased
libido)
Illness and time frame
Diagnoses
Psychiatric
Hospitalizations
Treatments
C. HEALTH MAINTENANCE
Immunizations (tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, varicella,
hepatitis B virus (HBV), human papilloma virus (HPV), meningococcal disease, Haemophilus
influenzae type B, pneumococci, and herpes zoster) COVID-19

Screening Tests (tuberculin tests, Pap smears, CXR,mammograms, stool tests for occult blood,
colonoscopy, biopsy, blood sugar, creatinine, uric acid, and cholesterol tests)
D. OTHERS
Allergies (Food, Drug, Dust, Pollen, Etc.) and history of adverse reactions
Medications (maintenance), Supplements, Herbals (Name, Dose, Frequency)

Trauma and Accidents; Travel

FAMILY HISTORY
Duration of marriage
Marital History
Occupation of partner
Number of children
Age of children and birth order
Children Similar symptoms with the patient
State of health, cause of death (if deceased)
If sick, age of onset and treatment
 Family member
Age and occupation
Familial Illnesses Similar symptoms with the patient
and Anomalies Hypertension /Coronary Heart Disease /Elevated Cholesterol Levels /Stroke/
(Parents, Siblings, Diabetes /Thyroid Or Renal Disease /Arthritis /Tuberculosis /Asthma Or Other/
Grandparents, Lung Disease /Headache /Seizure Disorder /Mental Illness /Suicide /Substance
Maternal and Abuse /Allergies /Cancer
Paternal Aunts
and Uncles) Genetically Transmitted Diseases

If present, pedigree is important

PERSONAL AND SOCIAL HISTORY
Personality and Interest, Source of support, Coping style, Strengths and concerns

Present and past

Occupation Income, social standing
Occupational hazards (working hours)
Educational Attainment
Home situation and significant others
Sources of stress (recent and long-term)
Life Experiences Military Service, Job History, Financial Situation, Retirement
Leisure Activities, Religious Affiliations and Spiritual Beliefs, Activities of Daily Living
Lifestyle habits Exercise and die, Usual daily food intake, Dietary supplements or restrictions
(that may Use of coffee tea, and other caffeinated beverages, Safety measures (use of
promote health or seatbelts, etc.)
create risk)
Sexual Orientation, Sexual Practices, Any alternative health care practices

Smoking Habits, Drug use, Alcohol use

House Owned/Not, Made Of?, Number of Rooms?, Bathrooms/ type of toilet,

Socioeconomic Ventilation, Pet, Who Lives Within The House, Distance From Health Center
History
Working members of the family, Sources of funds
Exposure to smoke
Exposure to other pollutants (specific pollutant and duration of exposure)
Hygiene (bathing, washing hands, brushing teeth, eating raw food, use of
Environmental serving spoons, food storage)
History Garbage Disposal (+Proximity), Sewage Disposal (+Proximity)
Water Source for Domestic Purposes, Water Source for Drinking, Neighborhood
(Assess Congestion)

GENERAL SURVEY

1. General state of health and build

2. Posture, motor activity, and gait
3. Dress, grooming, and personal hygiene
4. Odors of body or breath
5. Facial expressions: manner, affect and reaction to persons and
things in the environment
6. Manner of speaking
7. Level of consciousness or awareness
8. Signs of distress in posture or facial expression
9. Obvious signs of health or illness

VITAL SIGNS
Results Normal Values (appropriate for age) Interpretation
Temperature
Pulse 60-100
Respirations 12-20
Blood Pressure
Oxygen Saturation <90 is desaturation

ANTHROPOMETRIC MEASUREMENTS
Height/Length (cm)
Weight (kg)
BMI (kg/m2)
Head Circumference (cm)
Chest Circumference (cm)
Abdominal Girth (cm)

PHYSICAL EXAMINATION

Skin (Moisture, temperature, cyanosis/pallor, lesions, hair and nails)

HEENT Head
Scalp, skull, face (symmetrical, structural defects, lesions, masses and movability, edema,
involuntary facial movements, movability of temporomandibular joint)

Eyes
Visual acuity, position,symmetrical, and alignment, presence of discharges, lumps, lesions ,
bleeding, opacities, tearing,Eyelids (drooping), sclera (anicteric) and conjunctivae
(moist/dry/pinkish/yellowish/redness), pupils (PERRLA pupils equally round, reactive to light and
accomodation) extraocular movements (all 4 quadrants), proptosis

Ears
Symmetrical, deformities, lesions, dischanges, masses, Auricles, canals, and drums, acuity and if
absent, Weber and Rinne Test

Nose
Patent nares, Nasal mucosa, septum (midline), turbinates, discharges, lesions, tenderness of frontal
and maxillary sinus

Throat
Lips, (bleeding, swelling, dryness)oral mucosa, gums (bleeding, swelling), teeth (dentures), tonsils
(abscess and swelling), and pharynx

Neck
Cervical, tonsilar, submandibular, submental lymph nodes (levels of neck lymph node), masses, pulsations, vein
engorgement, deviation of trachea, sound and effort of breathing, thyroid gland (isthmus midline, rises when
swallowing), auscultation for bruit, pemberton sign
Mass: size, shape, consistency

Chest and Lungs

Inspect, palpate, percuss, level of diaphragmatic dullness, auscultate bronchial, bronchovesicular, and vesicular
breath sounds, rate and rhythm, retractions, adventitious sounds, transmitted voice sounds

Breast and Axilla

Inspect breasts with arms relaxed then elevated then pressed on her hips, axillary and epitrochlear nodes

Cardiovascular System
Blood pressure on all limbs, inspect for precordial bulge, sternal deformities, pulsations, vein engorgements,
jugular venous pulsation (elevate head -30ᴼ), palpate peripheral pulses, rate, rhythm, PMI, thrills and heaves,
auscultation of rpm, clicks, snaps, friction rubs. Grade (3+ = bounding; 2+ = brisk, expected (normal); 1+ =
diminished, weaker; 0 = absent, unable to palpate) the pulses: brachial, radial, femoral, popliteal, and pedal.

Abdomen
Inspect, auscultate (5-34 bowel sounds per min is normal), percuss for liver, kidneys spleen (tympanitic (gas)
dullness (fluid and feces), palpate for aorta and pulses, tenderness (direct and rebound), guarding

Peripheral Vascular System

Musculoskeletal System
Muscle or joint pain, stiffness, weakness, tenderness, limitation of motion

Nervous Mental Status, Cranial Nerves, Motor System, Sensory System, Reflexes
System

Genitals
Lumps, discharges, external and internal examination, and bimanual (women),penis and testicles (men), herniations
(Transillumination test)

Rectal
DRE:
inspect for visible masses, bleeding, discharges,
Check sphincter tone (good, lax, none)
Palpate for masses and adjacent structures(?)
*men- Palpate prostate gland (rubbery, firm, smooth)
Check for blood and stool in the examining finger
Take note of the length of finger reach (cm) from the anal verge

Nervous System
Glasgow Coma Scale
E-
V-
M-

Mental Status Exam

General behavior Normal, hyperactive, agitated, quiet, or immobile? If the Pt neat or slovenly?
and appearance Dressing in accordance with age, peers,
sex, and background?
Stream of talk Rapid, incessant, under great pressure, or is it slow and lacking in inflection and
spontaneity?
Mood affective Euphoric, agitated, inappropriately gay, giggling or silent?
responses
Content of thought Correctly perceives reality or have illusions, hallucination, delusions, obsessions?
Intellectual capacity Bright, average, dull, or obviously demented or mentally retarded?
Sensorium Consciousness; attention span; orientation for time, place, and person;
memory, recent or remote; calculation; fund of inform
Cranial Nerves Exam
CN I Sense of smell Check for patency first. Use simple odors (e.g. peel of orange) and let the Pt
identify the smell with each nostril with eyes closed.
CN II Visual Acuity, Have the Pt track an object and describe (usually a colored ball or a toy),
Fields, and follow movement of fingers, and use a Snellen Eye Chart at 14 inches away.
Ocular Fundi
CN II, III Pupillary Reactions Penlight for pupillary evaluation.
CN III, IV, VI Extraocular movements Use a colored object to track the 6 fields of cardinal gaze. A parent may need to hold
the Pt’s head.
CN V Corneal reflexes, facial Check for corneal reflexes and have the Pt close their eyes to test for
sensation, and jaw ophthalmic, maxillary, and mandibular sensation.
movements Have the Pt clench the teeth and chew or swallow some food.
CN VII Facial Movements Make the Pt grimace or smile, puff face.
CN VIII Hearing, Spatial Orientation Use tuning fork, music toys to elicit reflex response.
Test for lateralization (Weber), Compare AC and BC (Rinne’s Test) Normal AC>BC
CN IX, X Swallowing See feeding gag reflex, assess quality of cry or speaking voice, rise of palate.
CN V, VII, X, XII Voice and speech Hoarseness, nasal quality, phonation.
CN XI Head Movement Shoulder and neck movements.
Trapezius (Shrug shoulders against resistance)
 Sternocleidomastoid (Turn head against resistance)
*Pediatric: Observe head movements
CN XII Tongue Movement Tongue symmetry, position, and movement.
Motor System

Inspection Posture, general activity level, tremors, and other involuntary

movements
Palpate Atrophic, hypertrophic; with tenderness or spasms
muscles
Strength Scapular winging; biceps, triceps, wrist Grade strength on a scale from 0 to 5 or
Testing dorsiflexors, grip, finger abduction, and describe as paralysis or
extension; umbilical migration during a sit severe, moderate, or minimal weakness, or
up; hip flexors, abductors, knee flexors, normal. Record the
dorsiflexors, invertor’s and evertors pattern of any weakness such as proximal
versus distal, right versus
left, or upper extremity versus lower extremity.
Muscle tone Manipulate the joints to test for spasticity, clonus, rigidity or hypotonia,
and range of and range of movements
movements
Percussion of Percuss the thenar eminence for percussion myotonia and test for a
muscle myotonic grip if the Pt has generalized muscular weakness
Skin and Beevor’s sign (T8-T9), Cremasteric reflex
muscle (afferent L1, efferent L2), anal pucker reflex (S4-S5), bulbocavernosus
(superficial) reflex (S3- S4), and plantar reflex (Babinski’s maneuver; afferent S1;
reflexes efferent L5-S1-S2)
Sensory System
Pain Let the Pt differentiate between sharp or Analgesia refers to absence of pain sensation, hypalgesia
dull sensation. refers to decreased sensitivity to pain, and hyperalgesia
refers to increased pain sensitivity.
Temperature This test is often omitted when pain
sensation is normal.
Light Touch Use a fine wisp of cotton and avoid testing Anesthesia is absence of touch sensation, hypesthesia is
calloused skin decreased sensitivity to touch, and hyperesthesia is
increased sensitivity.
Vibration Use a relatively low-pitched tuning fork of Vibration sense is often the first sensation lost in a
128 Hz. Tap it on the heel of your hand and place it firmly over peripheral neuropathy and increases the likelihood of
a distal interphalangeal joint of the Pt’s finger, then over the peripheral neuropathy 16- fold. Causes include diabetes,
interphalangeal joint of the big toe. alcoholism, and posterior column disease,
seen in tertiary syphilis or vitamin B12 deficiency.
Proprioception Grasp the Pt’s big toe, holding it by its sides between your Loss of position sense, like loss of vibration sense, is seen
(Joint Position thumb and index finger, then pull it away from the other toes. in tabes dorsalis, multiple sclerosis, or B12 deficiency from
Sense) Demonstrate “up” and “down” as you move the Pt’s toe posterior column disease, and in diabetic neuropathy.
clearly upward and downward. Then, with the Pt’s eyes closed,
ask the Pt to say “up” or “down” when moving the large toe in
a small arc.
Discriminative Stereognosis, Number identification (graphesthesia), two-point
Sensations discrimination, point localization, extinction
Reflexes (Adult)
Scale for grading reflexes: 5 – sustained clonus, 4 – very brisk, hyperactive, and with clonus; 3 – brisker than average; 2 – average,
normal; 1 – somewhat diminished, low normal; 0 – reflex absent.
Reflexes How to Illicit Remarks
Jaw Jerk (CN V) With the Pt’s jaw sagging loosely open, rest a finger across the tip and
strike it a crisp blow.
Biceps The Pt’s elbow should be partially flexed and the forearm pronated with Observe flexion at the elbow, and
(C5, C6) palm down. Place your thumb or finger firmly on the biceps tendon. Aim watch for and feel the contraction
the strike with the reflex hammer directly through your digit toward the of the biceps muscle.
biceps tendon.
Brachioradialis The Pt’s hand should rest on the abdomen or the lap, with the Watch for flexion and supination
(C5, C6) forearm partly pronated. Strike the radius with the point or flat edge of of the forearm.
the reflex hammer, about 1 to 2 inches above the wrist.
Triceps Flex the Pt’s arm at the elbow, with palm toward the body, and pull it Watch for contraction of the
(C7, C8) slightly across the chest. Strike the triceps tendon with a direct blow triceps muscle and extension at the
directly behind and just above the elbow. elbow.
Finger Flexion (C7- Tromner’s method. The examiner supports the patient’s completely
T1) relaxed hand and briskly flips the patient’s distal phalanx upward, as
though to flip a handful of water high into the air. The patient’s fingers
 and thumb flex in response to the stretch of the finger flexor muscles.
Hoffman’s method. The examiner depresses the distal phalanx and
allows it to flip up. The extension of the phalanx stretches the flexor
muscles, causing the fingers and thumb to flex. This method is effective
only with very brisk muscle stretch reflexes.
Quadriceps (Patellar) The Pt may be either sitting or lying down as long as the knee is flexed. Note contraction of the quadriceps
(L2, L3, L4) Briskly tap the patellar tendon just below the patella. Place your hand with extension at the knee.
on the Pt’s anterior thigh.
Achilles (Ankle) If the Pt is sitting, partially dorsiflex the foot at the ankle. Persuade the Watch and feel for plantar flexion
(Primarily S1) Pt to relax. Strike the Achilles tendon. at the ankle.
Abdominal Test the abdominal reflexes by lightly but briskly stroking each side of Note the contraction of the
the abdomen, above (T8, T9, T10) and below (T10, T11, T12). abdominal muscles and movement
Abdominal reflexes may be absent in both central and peripheral nerve of the umbilicus toward the
disorders. stimulus.
Toe Flexion (S1-S2) Rossolimo’s sign. A muscle stretch reflex. The maneuver is identical
with the finger flexion method. Tapping the ball of the foot also elicits
toe flexion.
Plantar Response Stroke the lateral aspect of the sole from the heel to the ball of the foot, Dorsiflexion of the big toe is a
(L5, S1) curving medially across the ball. positive Babinski response, arising
from a CNS lesion affecting the
corticospinal tract.
Anal Using a broken applicator stick or pinprick, lightly scratch the anus on Watch for reflex contraction of the
(S2, S3, S4) both sides. external anal sphincter.
Cerebellar Exam
Test How to Illicit Remarks
Rapid Alternating Arms. Show the Pt how to strike one hand on the thigh, raise the hand, Observe the speed, rhythm, and
Movements turn it over, and then strike the back of the hand down on the same smoothness of the movements.
place. Urge the Pt to repeat these alternating movements as rapidly as Repeat with the other hand.
possible. The nondominant hand may
Fingers. Show the Pt how to tap the distal joint of the thumb with the perform less well.
tip of the index finger, again as rapidly as possible.
Legs. Ask the Pt to tap the ball of each foot in turn as quickly as
possible on your hand or the floor. Note any slowness or
awkwardness. Normally the feet do not perform as well as the hands.
Point-to-Point Arms: Finger-to-Nose Test. Ask the Pt to touch your index finger and Observe the accuracy and
Movements then his or her nose alternately several times. Move your finger so that smoothness of movement, and
the Pt has to change directions and extend the arm fully to reach your watch for any tremor.
finger. Normally the Pt
Now hold your finger in one place so that the Pt can touch it with one touches the examiner’s finger
arm and finger outstretched. Ask the Pt to raise the arm overhead and successfully with eyes open or
lower it again to touch your finger. After several repeats, ask the Pt to closed. These maneuvers test
close both eyes and try several more times. Repeat on the other side. position sense and the function of
Legs: Heel-to-Shin Test. Ask the Pt to place one heel on the both the labyrinth of the inner
opposite knee, then run it down the shin to the big toe. Observe this ear and the cerebellum.
movement for smoothness and accuracy. Repetition with the Pt’s eyes
closed tests for position sense. Repeat on the other side.
Gait Walk across the room and come back. Observe posture, balance, Normally balance is intact, the
swinging of the arms, and movements of the legs; arms swing symmetrically at the
Tandem walking: sides and turns are smooth.
walk heel-to-toe in a straight line; Walk on the toes, then on the heels;
Hop in place; Do a shallow knee bend; Rise from a sitting position and
step up on a sturdy stool
Stance The Romberg Test: This is mainly a test of position sense. The Pt Note the Pt’s ability to maintain an
should first stand with feet together and eyes open and then close both upright posture. Normally any swaying is
eyes for 30 to 60 seconds without support. minimal. Normally Pts hold this arm
Test for Pronator Drift. The Pt should stand for 20 to 30 seconds with position well.
eyes closed and both arms held straight forward with palms up.
Meningeal Signs
Test for these important signs whenever you suspect meningeal inflammation from meningitis or subarachnoid hemorrhage.
Meningeal Signs How to Illicit Remarks
Neck Mobility/Nuchal With the Pt supine, place your hands behind the Pt’s head and flex the neck
Rigidity forward, if possible until the chin touches the chest. Normally the neck is supple,
and the Pt can easily bend the head and neck forward.
Brudzinki Sign As you flex the neck, watch the hips and knees in reaction to your maneuver.
Normally they should remain relaxed and motionless.
Lasegue’s Sign The Pt lies supine with the legs relaxed. Grasp the calf or heel of the affected limb,
dorsiflex the foot, and elevate it gently as far as possible, flexing the hip while
keeping the knee straight.
Both maneuvers stretch the sciatic nerve and elicit pain if the nerve roots are
inflamed, compressed, or imprisoned by a mechanical lesion.
Kernig Sign Flex the Pt’s leg at both the hip and the knee, and then slowly extend the leg and
straighten the knee. Discomfort behind the knee during full extension is normal but
should not produce pain.