The Routine History and Physical Examination
After 50 years of practicing medicine, the author has discovered many productive and time-saving methods in taking a history and performing a physical examination. He believes these techniques are worth passing on to younger clinicians.
This section will examine each part of the history and demonstrate how to obtain the most information in the shortest period of time.
Development of the Chief Complaint
The physician begins this portion of the history by visualizing a strength–duration graph (Figure 1). It is important to know the following:
The intensity of a symptom, when and how it began, and its duration.
If the symptom onset was sudden or insidious.
If the symptom is steady, progressive, or intermittent.
The exact location of the symptom and whether it radiates to other areas of the body.
What other symptoms are associated with it and what precipitates it, aggravates it, and relieves it.
Chest pain can be used as an example. Depending on the information the physician gathers about the chest pain, he or she may reach different conclusions about it. This is graphically displayed in Figure 1.
If it is severe, think myocardial infarction or pneumothorax.
If it is mild to moderate, think Tietze syndrome, pleurisy, or pericarditis.
If it is intermittent, think angina pectoris or Tietze syndrome.
If it is steady, think pleurisy, myocardial infarction, fracture, pericarditis, or pneumothorax.
If it radiates to the jaw or the left upper extremity, think coronary artery disease.
If it is associated with dysphagia, think reflux esophagitis.
If it is precipitated by exercise, think angina pectoris.
If there is associated diaphoresis, think myocardial infarction or some other form of coronary artery disease.
If it is associated with fever and chills, think pleurisy, pneumonia, and pericarditis (strong possibilities).
If it is relieved by an antacid or lidocaine (Xylocaine) viscous, it is probably reflux esophagitis.
If it is relieved by nitroglycerin, it is probably angina pectoris. (Remember, nitroglycerin can also relieve esophagitis.)
The principles demonstrated by this example of chest pain can be applied to almost any symptom.
The clinician should always ask if there have been previous accidents, operations, or hospitalizations. He or she would also want to know if there is a history of contagious disease such as hepatitis, tuberculosis, recurrent pneumonia, gonorrhea, human immunodeficiency virus (HIV), or syphilis. To make the past history inquiry more complete, it is important to remember the following pearl: Ask if the patient has ever had any eye disease, ear–nose–throat (ENT) disease, lung disease, liver disease, kidney disease, skin disease, blood disease, bone disease, or endocrine disease. In other words, take each internal organ from head to toe and ask if the patient has a history of disease of that organ. This will not only result in a more thorough past history inquiry but almost certainly save an enormous amount of time.
Review of Systems
Here is another area where the physician can use a unique method to cover the entire body in an organized way, thus saving a lot of time. Because symptoms are organized into five categories, as emphasized subsequently in this book, one simply asks the following questions: