An Overview of Physical Examination 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 patient relationships, focuses your patient assessment, and setsthe direction of your clinical thinking. The quality of your history and physical examination governs your next steps with the patient and guides your choices from the initially bewildering array of secondary testing and technology. Over the course of becoming an accomplished clinician, you will polish these important relational and clinical skills for a lifetime. As you enter the realm of patientassessment, you begin integrating the essential 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 expand, and the steps of clinical reasoning will soonbegin with the ﬁrst moments of the patient encounter: identifying problem symptoms and abnormal ﬁndings; linking ﬁndings to an underlying process of pathophysiology or psychopathology; 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 allpatients also shape the image of the unique human being entrusted to your care.
Clinical Assessment: The Road Ahead
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’sstory; it gives an approach and overview to the physical examination and suggests a sequence for ensuring patient comfort; and, ﬁnally, it provides an example of the written record, showing documentation of ﬁndings from a sample patient history and physical examination. By studying the subsequent chapters of the book and perfecting the skills of examination and history taking described, you will crossinto the world of patient assessment— gradually at ﬁrst, but then with growing satisfaction and expertise. After you work through this chapter to chart the tasks ahead, you will be directed by subsequent chapters in your journey to clinical competence. Chapter 2, Interviewing and the Health History, expands on the techniques
CHAPTER 1 s AN OVERVIEW OF PHYSICAL EXAMINATION AND HISTORY TAKING
1THE HEALTH HISTORY: STRUCTURE AND PURPOSES
and skills of good interviewing; Chapters 3 through 16 detail techniques for examining the different body systems. Once you master the elements of the adult history and examination, you will extend and adapt these techniques to children and adolescents. Children and adolescents evolve rapidly in both temperament and physiology; therefore, the specialapproaches to the interview and examination of children at different ages are consolidated in Chapter 17, Assessing Children: Infancy Through Adolescence. Finally, Chapter 18, Clinical Reasoning, Assessment, and Plan, explores the clinical reasoning process and how to document your evaluation, diagnoses, and plan. From this blend of mutual trust, respect, and clinical expertise emerges thetimeless rewards of the clinical professions.
THE HEALTH HISTORY: STRUCTURE AND PURPOSES
As you read about successful interviewing, you will ﬁrst learn the elements of the Comprehensive Health History. For adults, the comprehensive history includes Identifying Data and Source of the History, Chief Complaint(s), Present Illness, Past History, Family History, Personal and Social History, and Review...