PCM Guidebook for 
        History Taking and Physical Exams 
        
        
                                               
        
                PATIENT CENTERED MEDICINE 
                   OFFICE OF EDUCATION 
        
                                           
        
          Copyright Rutgers Robert Wood Johnson Medical School 
        
                        PCM 2009-2017 
                  
                  
                 This guide is designed to provide the following 
                 information: 
                                                                                 SECTION                                                                                                                       PAGES                                                   
                      This book was developed by the multidisciplinary steering 
                      committee for Patient Centered Medicine.  It is meant to be a guide 
                      for your patient encounter.  For further detail, please see your 
                      textbook and speak with your clinical supervisor. 
                      How to elicit a Patient Centered History                                                                                                                              Pages 3 -7 
                      and History of the Present Illness 
                                       •                The Past Medical History                                                                                                            Page 8 
                                       •                The Family History                                                                                                                  Page 9 
                                       •                The Social History                                                                                                                  Pages 10-20 
                                       •                How to elicit a Review of Systems                                                                                                   Pages 21-30 
                      How to perform a Physical Exam                                                                                                                                        Pages 31–48 
                      The Pediatric Patient                                                                                                                                                 Pages 49–59 
                      The Write-up                                                                                                                                                          Pages 60–67 
                      Appendices 1-9 and Notes                                                                                                                                              Pages  68-79 
                  
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        HOW TO ELICIT A PATIENT CENTERED 
               HISTORY AND HISTORY OF 
                 THE PRESENT ILLNESS 
    
    Opening and facilitating the interview - Key actions 
       1.   Wash your hands before and after encounter 
       2.   Introduce yourself (state your first and last name 
           and that you are a medical student) to patient and 
           anyone else who is with the patient. Include who 
           you are working with (attending or resident name). 
       3.   Address the patient appropriately (use patient’s last 
           name or preferred name and personal pronoun)  
           Identify patient with first and last name and ask 
           how they would like to be addressed. 
       4.   Explain the purpose of the interview 
       5.   Offer a social comment or ask a non-clinical 
           question to put patient at ease 
       6.   Assure privacy and pull curtains as appropriate 
       7.   Assure comfort 
       8.   Sit down in a chair if feasible 
       9.   Allow the patient to express themself 
       10. Ask if patient has any questions and    
             respond to questions appropriately 
       11. Adapt your language, pace, and posture in 
           response to the patient 
       12. Present yourself professionally both verbally and 
           nonverbally 
       13. Demonstrate empathy, concern, and 
           compassion 
        
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      Closing the Interview – Key actions  
     1.  Consider summarizing key history and physical exam 
        findings   
     2.  Provide an explanation of what you think is going on 
        – working diagnosis, other possible diagnoses  
     3.   Provide specific next steps  
     4.   Ask patient/family if they have questions  
     5.   Ensure understanding – “teach-back”  
     6.   Thank patient.  
       
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