Written by: Ken Wilkens MSIII

Illustrations by: Regina Gandica MSIII

This book is intended to serve as an aid to learning the art of history taking and physical
diagnosis. Although it may seem overwhelming at first to have to "remember all these
questions", it will get easier. With practice and repetition, each of you will develop your
own style of interrogation, and own pattern of performing physical exams. I reorganized
the "blue book" in this manner because it provided me with a logical progression through
the history questions, and uses a head-to-toe anatomic approach to the physical. I would
recommend however, trying to memorize the questions within each category because it
will make for smoother interviews if the questions are on the tip of your tongue.
Classmates of mine, with whom I shared this book, found it helpful, as I hope you will.
Use the parts of the book that you like, disregard those you do not, and feel free to add
your own helpful hints for future editions. Good luck, and have fun. --KW

HISTORY
At some point during the interview, find out the patient's age, race, and regular physician.
Asking a battery of closed ended questions of "identifying information" right in the beginning
isn't the best way to establish rapport or ensure a smooth interview.
I. CHIEF COMPLAINT
(put in the patient's own words whenever possible)
II. PRESENT ILLNESS (CLOS-SIT)
(this is an easily learned mnemonic that I run through in my head whenever I'm getting an HPI.
It provides a good general backbone for any C.C.)
Characterize
Localize and radiation
Onset, duration and progression, frequency
Severity (1-10), aggravating/relieving factors
Setting, associated manifestations
Impact on ADL's
Therapy
Meaning to patient
CLARIFYING QUESTIONS:
(these are especially helpful when histories are unclear, or the complaints are chronic)

Why Today?
When was the last time you felt well?
What do you think it is?
Has this ever happened to you before?
Does it affect your sleep?
PERTINANT ROS/PMH/FH/SH
(pertinant +'s and -'s from these remaining categories ARE INCLUDED IN THE HPI. For
example if a pt comes in with chest pain, it is important in the HPI to know his cardiorespiratory ROS, prior history of cardiac problems, alcohol/tobacco/drug use, diet history,
family history of cardiac problems...)

III. PAST HISTORY

(the way I proceed through this is as follows: you can start out by asking "how do you generally
feel". Then I start with what comes first chronilogically, Childhood. When you're a child, you
get Immunized. Next, you grow up and become an Adult. If you remember the adult illnesses,
the last one is psychiatric. Psych. patients may have more Accidents, when you have an
accident, you go to the hospital, at the hospital, you have Surgery, and during surgery, you get
Transfusions. See how easy that was, now all you have to remember is Meds. People can get
addicted to medications, i.e. drug Habits. Drugs can also yield Allergies. The allergy questions
ask about Food allergies, which clues you to ask about diet. The last thing to remember is that it
your patient is female, to ask about OB/GYN Hx. As a general rule in the past history, you
should ask all those "question words" from elementary school: who, what, where, why, when,
how...)

General Health
Childhood Illnesses Measles, mumps, rubella, polio, chicken pox, scarlet fever, rheumatic fever
Immunizations MMR, DPT, polio, etc, last tetanus booster, last PPD and result

Adult Illnesses Important illness, Specifically: HTN, CAD, COPD, Tb, D.M., psychiatric
Accidents Serious injuries resulting in unconciousness, Fx, penetrating wounds
Hospitalizations reasons, treatment, outcome, location, dates
Surgical History indications, complications, dates
Transfusions number, date (before '85 in USA for HIV preacautions), reason, rxns
Current Medications prescription
(borrowed), OTC, home remedies, herbs, vitamins,
24hr pd.
*
o
Habits EtOH-->C.A.G.E.* , tobacco (ask if they ever considered quitting=2 prevention),
drugs/route (IVDA is important, needle sharing?), coffee
Allergies and manifestations drug, seasonal, contrast dye, food (shellfish)
++
Dietary History Meal examples and snacks, Ca intake
Ob-Gyn History GPFPAL and complications, birth control, menarche age, LMP, recent Pap.,
mammogram, Post-menopausal (onset sx, bleeding, ERT)

* Did you ever feel you had to Cut down on your drinking?
Have you ever been Annoyed by others talking about your drinking habits?
Did you ever feel Guilty about your drinking habits?
Did you ever use alcohol as an Eye opener in the a.m.?
(a positive answer to 1 of these questions requires further investigation)

IV. FAMILY HISTORY

Parents, Siblings, Spouse, Children Living (age, health), Dead (date, age, cause) Inquire:
HTN, heart disease, renal disease, DM, gout, arthritis, bleeding d/o, cancer, EtOH/Drug abuse

V. SOCIAL HISTORY (GLOM)

Geographic Birthplace, travel hx, current residence
Lifestyle Home situation, typical day, support system, activities/hobbies, exercise, pets
Occupation Education, profession, exposures (WATER)*
Marital Status/Sexual History # marriages and duration, current sexual activity, extramarital
relations (STD, "safe sex" precautions, homosexual contact)
*Work, Associated sx with work, Toxic agents at work, Environmental exacerbators of sx,
Resources (consult specialists)
VI. ROS
(some ot the questions can be remembered by the general themes of: pain, loss of function,
blood from opening. You can ask the ROS in a head-to-toe method as well. Try to make little
associations as well e.g. with head I think: "if you get dizzy, you might faint, if you faint, you
may hit your head and lose consciousness, and get head trauma, which would give you a
headache, and maybe even seizures...")
General Weight changes (loss associated w/ dieting?), appetite changes, unexplained fevers,
night sweats
Skin and Hair Rashes (distribution), itching, bruising, changes in skin color, jaundice, hair or
nail changes

Head Vertigo, syncope, LOC, trauma severe/debilitating headaches (lateralization, assoc.

neurologic sx), seizures, difficulty thinking, concentrating or communicating
Eyes Visual changes, diplopia, amaurosis fugax, halos, pain, corrective lenses
Ears Loss of hearing, pain, d/c, tinnitus
Nose Change in olfaction, epistaxis, d/c, obstruction, pain
Mouth and Throat Soreness, bleeding gums, serious dental problems, sore throats, voice
changes, dysphagia, odynaphagia
Neck Lumps in thyroid, goiter, heat/cold intolerance, nervousness, diaphoresis, tremors,
polydipsia, change in ring/shoe/hat size
Lymph Nodes/Hematopoetic Swollen glands, easy bruising
Chest and Lungs Cough, sputum production (amt., color, character), wheezing, hemoptysis,
pleuritic pain, dyspnea (quantitate w/ # of stairs/blocks)
Breasts Pain, lumps, galactorrhea
Cardiovascular Pain, dyspnea(quantitate w/# of stairs/blocks), PND, orthopnea, palpitations,
murmur hx, cyanosis, HTN, claudication, edema
Abdomen Appetite, heartburn, food intolerance, abdominal pain (meal related?),
nausea/vomiting, hematemesis, flatulance, diarrhea/constipation, changes in bowel
habits/frequency of movements, color/character of stool, rectal pain/bleeding, hemorrhoids,
hematochezia, melena
Extremeties Color changes, sensory changes, shooting pains, muscle weakness/cramps,
claudication, joint inflammation (R/H/S/P/L) (activity related, a.m. stiffness, single v. multiple,
migratory), f(x)'l ability (ADL w/o wheelchair/walker)
Genitalia (think about functions, don't forget to ask about sexual habits) Dysuria, hematuria, polyuria,
nocturia, incontinence, frequency, urgency, hesitancy, change in strength of stream, day/night
voiding pattern, renal stones, infection, abnormal UA hx, hernia. Sexual habits (frequency of
intercourse, libido, difficulties), potency, coital pain, d/c.
Psych Depression hx, sleep habits (in bed or chair), suicidal ideations/plans, hallucinations

PHYSICAL WASH HANDS!!!

(assess function then structure helps remember to do a lot of things especially on the HEENT
exam. Unless asked to specifically do a cranial nerve exam, you can forget about doing it
separately. You test most of them when doing your HEENT)

Vitals Temp., Pulse, RR, BP, height/weight

General Appearance
Skin and Hair Skin (pigmentation, moisture, temperature), hair (distribution, quantity, quality,
texture), petechiae, ecchymoses, telengectasias, skin lesions (color, morphology, arrangement,
distribution), decubitus ulcers, edema, deformity, discoloration
Head Symmetry, irrregularity, scars, quality and texture of hair, dandruff (as early psoriasis).
(you can have the patient bite down while feeling the head to test V3 masseter/temporalis)
Eyes Visual acuity (CN 2), visual fields, lids, conjuntivae, sclerae, cornea, EOM( CN 3,4,6),
pupils (size, PERRLA), opthalmoscope (disc, retina, macula)
Ears Gross assessment of hearing, whispered acuity, Weber, Rinne (CN 8), external ear,
otoscope (canal,drum, light reflex)
Nose Test smell (CN I non-caustics, e.g. coffee) external nose, septum, turbinates, sinuses
(tenderness, transillumination), airflow through both nostrils

Mouth and Throat Breath, lips, buccal mucosa, gums, teeth (dentures?), protrude/lift tongue
(CN 12), pharynx (CN 9,10), tonsillar area, voice (quality, character)

CN 5(1,2,3), 7, 5&7
(here's where you can test these cranial nerves that you haven't hit yet. V1,2,3, with sensation on
the face, VII with facial muscle movement, or you can test V1 and VII together with the corneal
blink reflex)
Neck Symmetry, movement, CN11, flexibility, pulsations, masses, trachea, palpate thyroid
(nodules?), parotid gland, submandibular gland, JVP, carotid pulsations (amplitude,
characteristics)
Lymph Nodes Occipital, submandibular, submental, cervical, supraclavicular (size, tenderness,
mobility, consistency)
Chest and Lungs Skin, inspect contour of chest, motion, accessory muscle use, palpate
symmetry of movement, tenderness, vocal fremitus, percuss for resonance, position of lung
bases, excursion of diaphragms, auscultate (rales, wheezes, rubs, egophony)...listen during forced
expiration as well, SPINE (tenderness, mobility), SACROILIAC (tenderness), POSTSACRAL
(edema), CVA (tenderness to gentle fist percussion)
Breasts (supine upright position) areola and nipple (size, position, tenderness, d/c, tumor), skin
dimpling, palpate (tenderness, cysts, tumors), axillary nodes

Cardiovascular Inspect for PMI (note interspace, and cm. from mid-sternal line), palpate
(thrills, rubs, heaves, tenderness), auscultate (rate, rhythm, intensity, duration S1, S2 (A2/P2),
timing and relationship of the sounds, clicks, m/g/r), describe murmurs (timing, duration,
intensity, pitch, site of maximal intensity, effect of position, hand grip, and respiration, valsalva),
localize any friction rub
Auscultate Carotid Artery

Abdomen Inspect (skin lesions, contour, venous patterns, scars), auscultate (bowel sounds 4Q,
bruits), percuss (liver size, shifting dullness), palpate (spleen presence, all quadrants for
light/deep tenderness, or masses), cremasteric reflex, inguinal area (masses, hernias, nodes)
Murphys, Rovsings, Obturator, Psoas, Referred Rebound (these signs help you out more as a
third year student, but they are good to learn now if you want)
Hands Skin examination, nails (clubbing, petechiae, transillumination, lesions), cuticle, palms,
turgor, radial pulse (amplitude, characteristics), position sense

Up Arms->Musculoskeletal Light touch, 2-point discrimination, bones (masses, pain,

deformity), peripheral joints (redness, warmth, swelling, tenderness, stability, range of motion),
muscle (all major muscle groups strength and grade (0-5) atrophy, tremor, fasiculations,
spacticity, weakness, wasting), epitrochlear nodes, biceps tendon/triceps tendon (symmetry and
grade 1+ to 4+), finger to nose, rapid alternating movements
Feet Skin examination, nails (clubbing, petechiae, transillumination, lesions), cuticle, soles,
turgor/edema, dorsalis pedis/ posterior tibial (amplitude, characteristics), position/vib. sense,
plantar reflex, achilles tendon (symmetry and grade 1+ to 4+)

Up Legs->Musculoskeletal patella tendon (symmetry and grade 1+ to 4+), light touch, 2-point
discrimination, tuning fork, bones (masses, pain, deformity), peripheral joints (redness, warmth,
swelling, tenderness, stability, range of motion), muscle (all major muscle groups strength and
grade (0-5) atrophy, tremor, fasiculations, spacticity, weakness, wasting), popliteal pulse
(amplitude, characteristics), femoral pulse (amplitude, characteristics, auscultate bruits)
Genitalia (F) external genitalia (labia, urethra, glands, introitus), speculum (vagina, cervix),
bimanual checking tenderness, masses, mobility (vagina, cervix, body of uterus, adnexa)
Genitalia (M) penis (circumcision, scars, ulcerations, inflammation, d/c), testis/epididymis
(tumors, cysts, tenderness, enlargement)
Rectal Anal region (lesions, hemorrhoids, fissures), prostate (size, shape, symmetry,
consistency, tenderness), masses, bleeding, stool specimen (occult blood)
Mental Status Orientation (p/p/t), memory (i/r/r), insight, judgement, intellectual ability
Cerebellar gait, heel to shin, Romberg

NOTES
*APGAR (0,1,2)
Appearance (all blue/trunk pink/all pink)
Pulse (0/<100/>100)
Grimace (0/grim./grim. + cough)
Activity (limp/some/active)
Respiration (0/irreg./reg.)
*Routine checkup: immuniz., personal habits, gyn (mammo/pap), social
*DRY patients: check MM (eyes, mouth) and axilla