Past  History —Review   past   illnesses, surgical  procedures  and  dates  thereof,  and  all major  injuries. .  Family  History—Obtain  the  health  status of blood relatives, including their age if living and the  cause  of  death  if  deceased. .  Social  History—The  patient’s  personal habits, sex life, emotional adjustments, and work and  recreational  habits  are  of  importance. l  Marital  History—Health  of  spouse,  sex- ual  adjustment,  number  of  children  and  their health, and the emotional status of the marriage. NOTE:  Depending  upon  the  circumstances  and the   type   of   the   patient’s   complaint,   not   all questions are pertinent and should not be asked of  the  patient  in  every  case, .  Occupational  History—Where  the  patient works, what he or she does, who he or she works for,  how  long  in  that  position,  health  hazards in   that   area,   and   recent   changes   in   position or  authority  may  be  important  points  to explore. .   Include   past   environmental   conditions (i.e.,   ______ ________ visited,   areas   of   the country  visited). A   comprehensive   account   of   complaints referable to each body system in logical sequence from  head  to  toe  should  be  made  a  part  of  the history.  This  review  provides  a  thorough evaluation of the past and present status of each body system. It also permits the grouping of like symptoms  and  provides  a  double  check  to prevent  omissions  of  significant  data  concerning the  present  illness  or  injury.  The  following  is merely a suggested guideline to follow and should not  be  interpreted  as  a  hard  and  fast  rule  of thumb. Again, each case is unique and should not be  stereotyped. .  Body  Weight—Determine  the  average, maximum, and least weight for the individual, and check  for  loss  or  gain  in  weight  and  the  time interval  between  such  loss  or  gain. .  Skin,  Hair,  and  Nails—Check  the  texture for   dryness,   sweating,   discolorations,   itching, changes  in  temperature,  dermatological  conditions and  therapeutic  efforts  to  control  them,  and baldness  and  itching  of  the  scalp. .  Head—Determine  if  there  are  headaches, their  frequency,  duration,  and  what  time  of  day they occur; be alert for and determine the presence or  absence  of  vertigo,  lightheadedness,  fainting, and  any  signs  of  trauma. .  Eyes—Ask  about  disturbances  in  vision, lacrimation,   itching,   photophobia,   and   pain. l  Ears-Determine  the  degree  of  deafness  (if suspected), pain, discharge, vertigo, and tinnitus. .   Nose—Note   any   discharges   or   obstruc- tions.  Ask  the  patient  if  he  or  she  is  subject  to frequent colds or allergies and if there has been any  change  in  the  sense  of  smell. .  Mouth  and  Throat—Ask  about  pain  and history   of   bleeding   gums,   sore   throats,   voice changes,  and  dysphagia  (difficulty  in  swallowing), and look for indications of dental hygiene habits. l   Neck—Determine   if   there   are   stiffness, swelling, pain and associated symptoms of lymph node  enlargement,  and  limitation  of  motion. .   Respiratory   System—Check   for   com- plaints   of   dyspnea,   orthopnea,   edema,   cough (productive  or  nonproductive,  and  if  productive, odor  and  color  as  well  as  amount  of  sputum), pain,  wheezing,  palpitation,  syncope,  cyanosis, hypertension,  hoarseness,  and  stridor  (harsh  or high-pitched  respirations). l   Cardiovascular   System—Ask   about exertional   dyspnea,   paroxysmal   nocturnal dyspnea,  chest  pain,  angina,  myocardial  infarc- tion,   claudication,   orthopnea,   varicosities, phlebitis   and   circulatory   problems   in   the extremities,  particularly  with  exposure  to  cold (Raeynaud’s),  heart  murmurs,  etc. .   Gastrointestinal   System—Ask   about changes  in  appetite,  complaints  of  dysphagia, pyrosis,  indigestion,  nausea,  vomiting,  blood  in stool   or   vomitus,   flatulence,   jaundice,   pain, changes  in  bowel  habits,  constipation,  diarrhea, and   hemorrhoids. l  Genitourinary  System—Ask  about  fre- quency  of  urination,  including  urgency,  hesita- tion, pain, blood, absence or diminishing amount, pus,  color,  and  dribbling  or  incontinence;  and check  for  past  or  present  evidence  of  sexually transmitted  diseases  (STD). 

   
 
Nervous   System—Check   for   feelings   of anxiety,   apprehension,   tremors,   convulsions, history  of  psychiatric  care,  changes  in  memory, changes  in  judgment,  pain,  paresthesia  (numb- ness),  paralysis,  and  coordination. .  Musculoskeletal  System—Note  the presence  of  muscular  pain,  swelling,  deformity, disability or pain in joints, weakness, atrophy, and cramps. PHYSICAL    EXAMINATION After   getting   as   much   information   as possible  from  questioning,  a  physical  examina- tion must then be performed. In general, use the same system format that was employed in taking the  medical  history.  (NOTE:  As  stated  in  the section  on  history  taking,  depending  upon  the complaint   of   the   patient   and   your   suspicions of  his  or  her  illness,  it  is  not  necessary  to perform  a  complete  physical  examination  in  every case.) . Vital Signs—Take and record temperature, pulse,  respiration,  and  blood  pressure l  Skin—The  human  skin,  which  is  some- times  referred  to  as  the  “mirror”  of  an  indi- vidual’s health because it often reflects diseases of other organs, should be examined visually and also   by   palpation. Observe  for  visible  ab- normalities   such   as   warts,   cysts,   scales,   and vesicles. An important point to remember in the visual examination of the skin is color. Changes in coloration are often tipoffs to various ailments; for  example,  a  bluish  tinge  can  indicate  congestive heart failure, pneumonia, or any other condition in  which  the  oxygen  content  of  the  hemoglobin is  reduced.  Changes  in  skin  coloration  can  also be caused by abnormal deposits of pigmentation, such as increases of bilirubin in the skin and sclera as   found   in   jaundice.   Note   the   temperature, texture,   elasticity,   moisture,   and   presence   or absence of edema. It is important to include the epidermal appendages in the examination of the skin; for example, note the condition of the nail beds (matrix) since abnormalities in the matrix can often  indicate  local  or  systemic  disorders.  Con- dition  of  the  hair  can  also  indicate  local  or systemic  disorders,  such  as  coarse,  dry,  and brittle  hair,  as  found  in  many  cases  of  hypo- thyroidism. .   Head—Look   for   any   abnormal   head movements, such as spasms, tremors, and tilting. Note  the  size  and  shape  of  the  head.  Note  any signs  of  swelling,  discolorations  (especially  in facial  bones),  and  bloody  or  watery  discharge from the nose and ears. Test the sections over the sinuses  by  palpation  and  percussion  to  detect  any signs  of  tenderness.  Check  for  range  of  motion (provided  there  is  no  neck  injury).  Inspect  the eyes for normal extraocular movements, equality of   pupils,   pupillary   reaction   to   light,   and accommodation.  Check  for  position  and  align- ment   of   the   eyes, abnormal   protrusions, recessions, and spacing; note the position of the eyelids to the eyeballs; observe for swelling of the lacrimal apparatus; note any opacities in the lens and cornea and swellings or nodules in the con- junctival and sclera. Examine the oral cavity for signs  of  bleeding  or  inflamed  gums,  coating  or swelling  of  the  tongue,  ulcers,  inflamed  throat, pus,  and  condition  of  teeth. . Neck—When inspecting the neck, look for any   signs   of   asymmetry,   unusual   pulsations, growths,   stiffness   or   limitation   of   movement, enlargement  of  the  thyroid  gland,  and  swollen lymph nodes behind the ears, on the sides of the neck,  and  in  the  supraclavicular  area.  Test swallowing  ability. l Ears, Nose, and Throat—When inspecting the  ears,  include  the  external  ear.  This  area  is sometimes so obvious that it is often overlooked. Examine  the  external  auditory  canal  for  any  signs of  wax  or  trauma.  Note  the  position,  color,  and shape of the tympanic membrane. Look for signs of  blood,  pus,  redness,  or  swelling.  Test  for hearing  loss  by  using  a  tuning  fork,  a  ticking watch, or the human voice. Observe the nose for signs of swelling or trauma. Use a nasal speculum to check for obstructions, redness, and infection. Inspect  the  throat  for  signs  of  blood,  pus,  redness, swelling,    tenderness, and  any  swellings  or growths. Check the condition of the teeth, gums, tongue,  palate,  tonsils,  uvula. .   Respiratory   System—Determine   if   the patient  is  coughing  and  if  the  cough  is  produc- tive or nonproductive. If productive, examine the sputum  for  quantity,  color,  viscosity,  and  odor. Look for skeletal deformities or funnel chest and exaggerated   or   abnormal   posture.   Check   the accessory  respiratory  muscles  in  the  neck  for deformity.  Take  note  of  rate,  depth,  symmetry, and  pattern  of  respirations.  Palpate  the  chest  wall

for  tenderness,  crepitation,  masses,  and  ab- normal pulsations. Palpate for any signs of vibra- tions  or  thrills.  Percuss  the  chest  for  signs  of resonance,  hyperresonance,  tympany,  dullness, and flatness. Use a stethoscope to auscultate for abnormal  breath  sounds  such  as  rales,  rhonchi, and wheezing. Listen for abnormal voice sounds. . Cardiovascular System—Place the patient in a supine position. Palpate the chest wall in the area  of  the  left  midclavicular  line  to  detect  thrills, rate, rhythm, and precardial heave. Auscultate the heart for abnormal sounds such as friction rubs and heart murmurs. .   Gastrointestinal   System—Inspection, auscultation,  percussion,  and  palpation  are  of significant  value  in  examining  the  gastrointestinal system.  Most  of  the  information  gathered  from the  examination  will  be  from  palpation.  Always perform palpation last because some findings of auscultation can be markedly altered by manipula- tion of the abdomen. Place the patient in a supine position with the head slightly elevated. Visually inspect the exposed skin from the sternum to the pubis.  Observe  for  symmetry,  masses,  and  general nutritional  state.  Note  the  presence  of  scars, stretch marks, blemishes, a visible hernia, or ab- dominal   distension.   Auscultate   to   detect   any abnormal  peristalsis  sounds,  friction  rubs,  and bruits   (e.g.,   a   splashing   or   blowing   sound). Percuss  the  abdominal  area  to  detect  the  presence of   tumors,   fluid,   distension,   and   enlargement of   the   underlying   organs.   Palpation   of   the abdominal walls is the most important of all the steps  and  the  most  difficult  to  perform.  First, make sure your hands are warm. Start to palpate by  placing  your  hand  in  an  area  where  there  is no  pain  and  gently  move  your  hand  over  the entire  abdomen.  Note  any  enlargements  or  masses and  any  pain  produced.  When  examining  the abdomen,  you  should  be  alert  for  any  sign  of  a hernia.  There  are  three  types  of  abdominal hernias: ventral—soft masses that protrude into the  abdominal  wall  anteriorly;  inguinal—a protrusion of peritoneum through the abdominal wall  in  the  inguinal  area;  and  femoral-located on the anterior surface of the thigh just below the inguinal ligament. The last part of the examina- tion is the rectal. This part of the examination is crucial and should be performed in every case in- volving  the  gastrointestinal  tract.  The  perianal area should be inspected for lesions and external hemorrhoids.  Also  palpate  the  anal  canal  for tumors,   polyps,   masses,   and   tenderness.   The prostate should be palpated for size, shape, and consistency.  After  withdrawing  the  gloved  hand from the rectum, check the character of any stool that may be on the glove, and perform a guaiac test. .  Genitourinary  System—Inspect  the  lower abdomen   and   flank   area   for   any   signs   of tenderness  if  kidney  involvement  is  suspected. Whenever possible, do a microscopic examination of  the  urine.  Examine  the  genitalia  for  signs of   discharge,   ulcers,   growths,   phimosis,   para- phimosis,  condylomata  (venereal  warts),  cysts, lipomas  or  any  masses  (any  testicular  mass must  be  considered  as  cancerous  until  proven otherwise), and areas of tenderness and swelling (as in epididymitis). If not already performed, a rectal  examination  is  essential.  If  renal  calculi  are suspected,  screen  all  urine  for  signs  of  “sandy grit,”  pus,  blood. .  Extremities—Compare  upper  extremities for symmetry, muscular development, deformity, evidence   of   nail   biting,   redness,   warmth, tenderness,  and  crepitation.  Examine  the  joints for   range   of   motion,   areas   of   tenderness, swelling,  and  discoloration.  Inspect  and  palpate all lymph nodes in the upper extremities. Examine the legs for symmetry, edema, muscular develop- ment,   abnormalities   in   blood   vessels,   and dermatological  diseases.  Apply  passive  and  active range  of  motion  techniques  and  check  for tenderness,  swelling,  discoloration,  and  deformity in  joints.  Inspect  and  palpate  all  inguinal  and femoral  nodes.  Examine  the  feet  for  changes  in coloration or temperature-indicators of impaired circulation. .   Central   Nervous   System   Checks—The following  are  the  five  testing  categories  in  a neurological  assessment: l  Mental  Status  and  Speech—Note  the patient’s  dress,  grooming  and  personal  habits, expressions, manner, mood, speech, and level of consciousness. l Cranial Nerves—Test the olfactory and optic  nerves  by  having  the  patient  identify  smells, testing  visual  acuity  and  mobility  of  the  eyes, assessing  the  hearing,  and  observing  for  facial weakness  or  tics. l  Muscles—Test  for  muscle  tone,  co- ordination, involuntary movements, and atrophy.


Sensory  System—Test  for  sensations using  pain,  heat  or  cold,  touch,  and  vibration.

Reflexes-Check  deep  tendon  reflexes, superficial    reflexes, and   also   check   the pathological  reflexes  (i.e.,  Brudzinski’s  sign  and Kernig’s  sign).  Reflexes  are  checked  to  localize nervous  system  disorders.