History-Taking and Physical Examination

Rationale

The ability to obtain an accurate medical history and carefully perform a physical examination is fundamental to providing comprehensive care to adult patients. In particular, the internist must be thorough and efficient in obtaining a history and performing a physical exam with a wide variety of patients, including healthy adults (both young and old), adults with acute and chronic medical problems, and adults with complex life-threatening diseases.

The optimal selection of diagnostic tests, choice of treatment, and use of subspecialists, as well as the physician’s relationship and rapport with patients, all depend on well developed history-taking and physical-diagnosis skills. These skills, which are fundamental to effective patient care should be a primary focus of the student’s work during the core clerkship in general internal medicine.

Prerequisite

Introductory (required pre-clinical) course in physical diagnosis.

Specific Learning Objectives

1. Knowledge: Each student should be able to describe:
   1. the significant attributes of a symptom, including location and radiation, intensity, quality, temporal sequence (onset, duration, frequency), alleviating factors, aggravating factors, setting, associated symptoms, functional impairment, and patient’s interpretation of symptom.
   2. the four methods of physical examination (inspection, palpation, percussion, and auscultation), including where and when to use them, their purposes, and the findings they elicit.
   3. the physiologic mechanisms that explain key findings in the history and physical exam.
   4. the diagnostic value of history and physical exam information.
2. Skills: Each student should be able to:
   1. use language appropriate for each patient.
   2. use non-verbal techniques to facilitate communication and pursue relevant inquiry.
   3. elicit the patient’s chief complaint as well as a complete list of the patient’s concerns.
   4. obtain a patient’s history in a logical, organized, and thorough manner, covering the history of present illness; past medical history (including usual source of and access to health care, childhood and adult illnesses, injuries, surgical procedures, obstetrical history, psychiatric problems, hospitalizations, transfusions, medications, tobacco and alcohol use, and drug allergies); preventive health measures; social, family, and occupational history; and review of systems.
   5. obtain, whenever necessary, supplemental historical information from other sources, such as significant others or previous physicians.
   6. demonstrate proper hygienic practices whenever examining a patient.
   7. position the patient and self properly for each part of the physical examination.
   8. perform a physical examination for a patient in a logical, organized, respectful, and thorough manner, giving attention to the patient’s general appearance, vital signs, and pertinent body regions.
   9. adapt the scope and focus of the history and physical exam appropriately to the medical situation and the time available.
3. Attitudes: Each student should:
   1. recognize the essential contribution of a pertinent history and physical examination to the patient’s care by continuously working to improve these skills.
   2. establish a habit of updating historical information and repeating important parts of the physical exam during follow-up visits.
   3. demonstrate consideration for the patient’s feelings, limitations, and cultural and social background whenever taking a history and performing a physical exam.