Getting the Most out of Your History and Physical Examination
The main body of this chapter has been designed to get the most out of your history and physical examination in the shortest period of time. If you are like most busy primary care clinicians you are seeing 25 to 40 or more patients in a day. Not long ago, I was covering an Urgent Care practice in Palm Desert California and saw 37 patients in one 8-hour day. In this section, we will address the techniques of performing a history and physical examination like you have never witnessed before.
In medical school, you learned to methodically take your patients’ history beginning with the development of the chief complaint, following that with the review of system and medical, family, and social history. Then after having the patient undress and properly draped and placed on the exam table, you perform your physical examination methodically from head to toe, gathering all the necessary information you need to make a diagnosis.
Thereafter, you sit down and add up the positive findings and develop a list of possible diagnoses that could explain the patient’s chief complaints and proceed with your workup or treatment plan. This whole process could take an hour or more and in my opinion is putting the cart before the horse! How can you see 25 to 40 patients in an 8-hour day with this methodology?
Here is a cost-effective approach that will save you time and the patient money! But before we discuss this approach, I want to discuss something which you have probably never had a formal discussion about in your training or read in any medical text book. That is bedside manner.
First, make sure you are properly dressed. Street clothes or jeans should be replaced by an appropriate clean uniform, a shirt and tie or at least covered with a lab coat. Make sure you don’t have bad breath or a bad body odor. I keep a bottle of Benaca spray and an aftershave lotion handy at all times, so I can freshen up when needed.
Greet the patient with a warm smile and an energetic “Hello!” Introduce yourself properly if it’s the first time you have seen them. Never act like you’re in a hurry! The patient wants to know you care about him/her, so you must do everything you can to convince him/her that you do! Not just about his/her illness, but about him/her as a person. The patient needs to feel that he/she is the only patient you’ve got! To accomplish this, sit down and address his/her problem eye ball to eye ball, if possible. This is why I like to have two chairs at least in the examination room. Standing over a patient who is sitting or lying down on the exam table while you are doing your interview is a no-no in my opinion!
When you are talking to the patient maintaining as continuous eye contact as possible is axiomatic. Spending all your time looking at the computer or your notes conveys the impression that you care more about your records than them.
Do all you can to convey your compassion about their illness! A warm “I’m so sorry you’ve had to suffer” at the right time is a God-send to the patient and an integral part of therapy. Perhaps you’re the first person they’ve encountered who cares or even believes they are suffering.
Again, your examination of the patient needs to be slow, deliberate, and gentle. Explain what you are doing and when possible convey the results of the examination of each part. When you’re done with the history and physical examination, tell them what you believe is wrong and what you’re going to do about it.
Besides writing a prescription, write down a list of instructions they need to do themselves if appropriate. If you simply give them verbal orders, they may forget! For the most common disorders I encounter in my practice, I have typed copies of instructions that I give to the patient and explain each thing on the list I want them to do.
Now, to the techniques of a rapid history and physical examination. Before you begin asking questions or examining the patient, formulate a list of possible diagnoses in your mind based on the chief complaint. Then you will ask questions to rule in or rule out each possibility! With this technique, your history and physical examination will be more meaningful and enjoyable rather than the “robotic” method you learned in medical school.
I use the mnemonic MINT (M—malformation, I—inflammation, N—neoplasm, T—trauma) to formulate a list of possibilities in many cases, but you can use any mnemonic that suits you. Another way to form a list of possibilities is to visualize the anatomy of the area where the chief complaint is located. For example, if the patient is complaining of chest pain, you would visualize skin (abscess, herpes zoster, etc.), ribs (fracture, costochondritis, etc.), pleura (pleurisy), pericardium (pericarditis), heart and blood vessels (myocardial infarction, coronary insufficiency, dissecting aneurysm, etc.), lungs (pneumonia, pulmonary infarct, etc.), esophagus (reflux esophagitis, etc.), thoracic spine (herniated disk, fracture, osteoarthritis, etc.), and nerves (radiculopathy, herpes zoster, etc.).
Now, you will eliminate some of these on your history and physical examination. Then, you will be left with the ones you need to evaluate with your diagnostic workup or you can immediately treat without a workup.
Now, with the above techniques in mind, let’s apply them to the most common complaints you encounter daily in your primary care practice.
ACUTE ABDOMINAL PAIN
The author recommends using anatomy to formulate your lists of possibilities before you see the patient. Only the commonest causes will be dealt with here:
1. Gastroenteritis
2. Appendicitis
3. Cholecystitis
4. Peptic ulcer
5. Pancreatitis
6. Diverticulitis
7. Intestinal obstruction
8. Perforated viscus
9. Ectopic pregnancy
10. Pelvic inflammatory disease (PID)
11. Reflux esophagitis
12. Myocardial infarction
13. Renal calculus
14. Hepatitis
With these possibilities in mind, you will begin your interview by asking for the location of the pain. If it’s right upper quadrant (RUQ), consider cholecystitis or duodenal ulcer. If it’s epigastric, consider the possibility of pancreatitis, gastric ulcer, reflux esophagitis, and myocardial infarction. Pain in the right lower quadrant brings up the possibility of appendicitis, ectopic pregnancy, and PID, whereas pain in the left lower quadrant suggests diverticulitis, ectopic pregnancy, and PID. Diffuse
abdominal pain is consistent with gastroenteritis and peritonitis either primary or secondary to a ruptured viscus (ruptured peptic ulcer, etc.). Diffuse abdominal pain also suggests intestinal obstruction. Next, determine if the pain is constant (cholecystitis, appendicitis, diverticulitis, etc.) or intermittent (biliary colic, renal colic, intestinal obstruction).
abdominal pain is consistent with gastroenteritis and peritonitis either primary or secondary to a ruptured viscus (ruptured peptic ulcer, etc.). Diffuse abdominal pain also suggests intestinal obstruction. Next, determine if the pain is constant (cholecystitis, appendicitis, diverticulitis, etc.) or intermittent (biliary colic, renal colic, intestinal obstruction).
The severity of the pain may shed some light on the diagnosis. The most severe pain will be caused by acute pancreatitis, ruptured viscus, biliary or renal colic. Is the pain associated with meals? Pain from peptic ulcer and reflux esophagitis occurs 1 to 2 hours after meals, while pain from cholecystitis or cholelithiasis typically occurs 2 to 3 hours after meals.
Associated symptoms are usually the key to the diagnosis. Diarrhea, nausea, and vomiting are typical of gastroenteritis, while loss of appetite, mild nausea, and fever are more typical of appendicitis. Severe nausea and vomiting is common with cholecystitis, intestinal obstruction, pancreatitis, and renal colic. Look for a vaginal discharge if you suspect PID, and amenorrhea, morning sickness, and tender breasts if you suspect an ectopic pregnancy. A myocardial infarction should be suspected if there is severe diaphoresis without significant fever and a history of diabetes, hyperlipemia, or hypertension. Acute pancreatitis is suspected if there is a history of alcoholism, while reflux esophagitis should be suspected if there is a history of recurrent regurgitation of food or acid especially on lying down after a meal.
On your physical examination, always check for rebound tenderness. If this is in the RUQ, suspect cholecystitis. If it is localized to the right lower quadrant, suspect acute appendicitis. Rebound tenderness in the left lower quadrant is suspicious of diverticulitis. PID and ectopic pregnancy may also be associated with rebound tenderness in one or both lower quadrants. Diffuse rebound tenderness suggests pancreatitis or ruptured viscus, especially a ruptured peptic ulcer and peritonitis.
A tender mass in the RUQ suggests cholecystitis or hepatitis, while a mass in the right lower quadrant suggests a ruptured appendix. Look for a mass in the groin or umbilicus (hernia) in intestinal obstruction. Icteric sclera points to cholecystitis and hepatitis. Hyperactive bowel sounds are the rule in intestinal obstruction, while decreased or absent bowel sounds is highly suggestive of peritonitis or a ruptured viscus. Vaginal examination will reveal a tender adnexal mass in PID, ectopic pregnancy, and inflamed pelvic appendix. Look for Murphy’s sign if you suspect cholecystitis and Rovsing’s sign in appendicitis. A reverse Rovsing’s sign may be found in diverticulitis of the sigmoid colon. Years ago, the author discovered that a retracted testicle on the right was consistent with appendicitis, while a retracted testicle on the left was consistent with diverticulitis (not in females, of course). If both testicles are retracted, suspect peritonitis! Rectal examination may reveal gross blood in intussusception or mesenteric thrombosis, or occult blood in these conditions plus peptic ulcer disease, diverticulitis, and carcinoma of the bowel.
Your diagnostic workup is essential to confirm your impressions after a history and physical examination as well as to rule out other possibilities (page 16).
CHEST PAIN
Before you see the patient, develop a list of most likely possibilities using a mnemonic for the anatomy (skin, ribs, lungs, heart, thoracic spine, etc.):
1. Skin—cellulitis, herpes zoster, etc.
2. Ribs—fractures, contusions, costochondritis
3. Pleura—pneumonia with pleurisy
4. Lung—pneumothorax, pulmonary embolism, etc.
5. Heart—pericarditis, myocardial infarction, coronary insufficiency, etc.
6. Esophagus—reflux esophagitis (gastroesophageal reflux disease), cardiospasm, carcinoma
7. Thoracic spine—fractures, herniated disk, space-occupying lesion
Now, in your history, you ask the location of the pain: left precardium (myocardial insufficiency or infarct, pericarditis, etc.), while the pain with the rest of the conditions can be almost anywhere. You ask if the pain is precipitated by inspiration (pleurisy, costochondritis, pulmonary embolism, rib fractures, reflux esophagitis, etc.) or by extension or rotation of the spine (vertebral fracture, herniated disk, etc.). You ask if it is acute (pulmonary embolism, pneumothorax, pneumonia with pleurisy, fractures, costochondritis, myocardial infarction) or chronic or recurring (coronary insufficiency, reflux esophagitis, thoracic spondylosis, etc.). Does the pain radiate to the neck, jaw, or left upper extremity (myocardial infarction, coronary insufficiency)? Is it associated with diaphoresis (myocardial infarction, pulmonary embolism), hemoptysis (pulmonary embolism), regurgitation of food or acid (reflux esophagitis), or a rash (herpes zoster)?
On your physical examination, you can quickly identify costochondritis by palpating the costochondral junctions at the 2nd, 3rd, or 4th ribs (usually). You can identify rib fractures by palpating the ribs. You can identify pneumothorax by tracheal deviation and pulmonary embolism or pneumonia with pleurisy on auscultation of the lungs. Loss of sensation in the thoracic dermatomes and sensory, motor, and reflex changes in the lower extremities may help identify thoracic spondylosis, a herniated thoracic disk, or space-occupying lesion of the thoracic spine. Reflux esophagitis can be identified by reproducing the pain with pressure in the mid-epigastrium or relief of the pain with a swallow of 5 to 10 mL of lidocaine viscous. Further differentiation of these conditions may require a diagnostic workup (page 93) or referral to a specialist.
COUGH
Again, before you see a patient with cough, you develop a list of conditions to look for like this:
1. Acute bronchitis
2. Pneumonia
3. Tuberculosis (TB)
4. Bronchiectasis
5. Asthma
6. Pulmonary embolism
7. Congestive heart failure (CHF)
8. Chronic obstructive pulmonary disease (COPD)
9. Neoplasm
10. Reflux esophagitis
Now, in your history, you are looking for fever and chills and night sweats (an infections process) or if the cough is of recent onset (bronchitis pneumonia, CHF, and pulmonary embolism), chronic or long standing (TB, bronchiectasis, CHF, asthma, or COPD); purulent sputum (pneumonia, TB, or bronchiectasis); hemoptysis (TB, neoplasm, bronchiectasis, pulmonary embolism), shortness of breath (CHF, asthma, COPD, pulmonary embolism), and regurgitation of acid or food (reflux esophagitis). You are also looking for weight loss (neoplasm and TB).
On your physical examination, you are looking for crepitant rales and signs of consolidation or effusion (pneumonia, TB, CHF, pulmonary embolism); sibilant
and sonorous rales or hyperresonance (asthma, bronchitis, COPD); edema of one extremity and positive Homan’s sign (pulmonary embolism) or edema of both extremities; cardiomegaly, hypertension, hepatomegaly, jugular venous distension (CHF), or decreased oxygen saturation (CHF, COPD and pulmonary embolism).
and sonorous rales or hyperresonance (asthma, bronchitis, COPD); edema of one extremity and positive Homan’s sign (pulmonary embolism) or edema of both extremities; cardiomegaly, hypertension, hepatomegaly, jugular venous distension (CHF), or decreased oxygen saturation (CHF, COPD and pulmonary embolism).
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