The ability to obtain an accurate medical history and carefully perform a physical examination is fundamental to providing comprehensive care to adult patients.

<aside> ☝ In particular, the internist must be thorough and efficient in obtaining a history and performing a physical examination with a wide variety of patients, including healthy adults (both young and old), adults with acute and chronic medical problems, adults with complex life-threatening diseases, and adults from diverse socioeconomic and cultural backgrounds.

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The optimal selection of diagnostic tests, choice of treatment, and use of sub-specialists, as well as the physician’s relationship and rapport with patients, all depend on well-developed history-taking and physical diagnosis skills.

History

<aside> 📌 Symptom - subjective evidence of disease observed by the patient.

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1. Chief Complaint in the patient's own words
2. History of Present Illness (HPI)
   1. Lead sentence: Age, Sex, RELEVANT past medical history, and reason for presentation.
   2. Narrative of presenting illness in chronological order, using relative terms (e.g. "5 days ago" instead of "on July 4th")
   3. Additional Details (OLDCARTS)
      • Onset
      • Location
      • Duration
      • Character
      • Alleviating and Aggravating Factors
      • Related Symptoms
      • Timing (e.g. Constant, Intermittent)
      • Severity using a numbered scale
   4. Pertinent Negatives
      • A brief list of symptoms that are NOT present, which represent major branch points in the differential diagnosis for the presenting symptom. (e.g. In a patient with cough, "No fever" or "No recent weight loss" might be important branch points in the decision-making tree if infectious or neoplastic etiologies are on your differential.)
3. Review of Systems
   • Constitutional Symptoms
   • Eyes
   • Ears, nose, mouth, throat
   • Cardiovascular
   • Respiratory
   • Gastrointestinal
   • Genitourinary
   • Musculoskeletal
   • Integumentary (skin and/or breast)
   • Neurological
   • Psychiatric
   • Endocrine
   • Hematologic/lymphatic
   • Allergic/immunologic
4. Past Medical History including experiences with illnesses, operations, injuries, and treatments
   • Often, Surgical History is listed separately
5. Family Medical History including a review of medical events in the patient's family, and diseases which may be hereditary or place the patient at risk
6. Social History
   • Smoking, Alcohol, and Drug History
   • Functional Status: ADLs, iADLs
   • Social Support
   • Workplace Exposures
   • Education
   • Travel History
   • Sexual History
   • Hobbies and Environmental Context
7. Current medications
8. Drug and food allergies

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Physical Examination

<aside> 📌 Sign - objective evidence of disease, especially as observed and interpreted by the physician rather than by the patient or lay observer.

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Elements of A General Complete Examination:

1. Vital Signs: Temperature, Heart Rate, Blood Pressure, Respiration Rate, Oxygen Saturation and modality of respiratory support, BMI
2. Constitutional:
   • General Appearance: level of distress, toxic vs non-toxic, development, nutrition, body habitus, deformities, attention to grooming, etc.