Book Review  |   May 2008
The History and Physical Examination Workbook: A Common Sense Approach
Author Affiliations
  • Paul Evans, DO
    Georgia Campus—Philadelphia College of Osteopathic Medicine Suwanee, Ga
    Vice Dean
Article Information
Book Review   |   May 2008
The History and Physical Examination Workbook: A Common Sense Approach
The Journal of the American Osteopathic Association, May 2008, Vol. 108, 237-238. doi:10.7556/jaoa.2008.108.5.237
The Journal of the American Osteopathic Association, May 2008, Vol. 108, 237-238. doi:10.7556/jaoa.2008.108.5.237
There is a fine art to knowing and recognizing the signs and symptoms associated with each illness and to understanding how to craft questions—both open- and close-ended—in an efficient but sensitive manner during a patient interview and examination. In addition, the clinical intuition of the “hunch” (ie, impression based on prior clinical experience) should be allowed a place in the diagnostic process. 
The authors of The History and Physical Examination Workbook: A Common Sense Approach attempt to meld these concepts with an osteopathic approach to patient care. The text is designed for the clinical learning laboratory, with developmental exercises in taking medical histories and performing physical examinations formatted around “real-world” cases. Mark K. Kauffman, DO, is a primary care physician at the Erie (Pa) Veterans Affairs Medical Center and director of physical diagnosis for the Problem-based Pathway Program and clinical assistant professor of family medicine at the Lake Erie (Pa) College of Osteopathic Medicine. Michele M. Roth-Kauffman, JD, who also has a degree as a physician assistant, serves as chair of the Physician Assistant Department and associate dean of the College of Sciences, Engineering, and Health Sciences at Gannon University, also in Erie. 
The teaching approach used by the authors in this workbook is unique and appears to have been compiled from past teaching exercises. They present “flows” (ie, step-by-step lists of questions or procedures presented in a logical sequence) of both history-taking questions and physical examination procedures—along with a few mnemonic devices. The flows are intended for use by two partners—one acting as the physician and the other as the patient. Instead of relying on student memorization, the flows offer a logical process designed to assist clinicians in arriving at a working differential diagnosis for each case. For example, the “respiratory flow” list begins with the physician introducing him- or herself to the patient and explaining how the physical examination will be performed. The inspection steps are then presented, followed by steps for palpation (eg, symmetrical expansion, tactile fremitus), percussion (eg, diaphragmatic excursion), and auscultation (eg, adventitious sounds). Next, specialty test options are presented (eg, bronchophony, egophony), and, finally, possible clinical scenarios are suggested (eg, pneumonia, pneumothorax, pleural effusion). 
This workbook consists of six chapters. The first chapter discusses general thought processes and actions involved in obtaining patient histories. The second chapter discusses techniques of clinical history–gathering, and the third chapter provides history flows for 18 cases, including clinical presentations of ear pain, back pain, mole, urinary tract infection, cold, nausea and vomiting, and dizziness. 
Chapter 4 includes flows for physical examinations by body region. Chapter 5 consists of comprehensive flows—history and physical examination together—for various signs and symptoms (eg, shoulder pain, rash, itching, chest pain, drug abuse, forgetfulness, cough). 
The sixth, and final, chapter in the book covers the logistics of prescribing practices. 
Appendices feature information on documentation and common medical abbreviations. 
The authors' use of several “true stories” adds authenticity to the exercises. In these features, the authors share anecdotal experiences to emphasize teaching points. In one case, a patient who was embarrassed about contracting pubic lice told the nurse that he had “abdominal pain,” illustrating that the art of the medical interview sometimes includes investigating the patient's actual reason for visiting the doctor, rather than accepting the patient's stated reason. Another such case involved an elderly patient who initially described chest pain occurring after she lifted a garbage can. When another physician interviewed her, the patient gave a different pain story, describing her problem as squeezing, crushing pain on the left side of her chest that began after she dragged the garbage can 50 yards down the driveway. 
How many of us have encountered cases similar to these as a trainee or as an attending physician? Such cases are valuable for helping novice physicians understand the great variability of responses that can be elicited from a patient during the interview process. 
Many of the cases are useful in teaching students how to approach history-taking and physical examinations and how to formulate initial impressions of a case. The book includes a number of helpful details on various topics, such as a description of the Tanner stages of physical development. The description of the examination of the floor of the mouth is especially well done. The overall compilation of history and physical examination considerations in the book is fairly complete and organized in a way that uses repetition as a learning tool. 
An excellent feature in this book is the use of the osteopathic perspective as provided in the cases. There are also examples of osteopathic specialty board questions to highlight key concepts. 
Some areas of the workbook could be improved. Certain material (eg, description of blood pressure measurement, inclusion of patient education level in history taking) may be too detailed for inclusion in a workbook. There are a number of grammatical errors in the flow lists. Spelling mistakes, such as “hepatojugular reflex” instead of “hepatojugular reflux” and “blue blower” instead of “blue bloater,” are distracting to the reader. Other errors in editing include those of organization. For example, gait assessment is not included in the section on the musculoskeletal system. In some cases, there are errors of omission. For example, the case of an 88-year-old man who fell on his buttocks includes no mention of a rectal examination to assess the coccyx. In another case report, oxygen was not suggested for a patient with acute myocardial infarction. It is my hope that such shortcomings will be addressed in future editions of the workbook. 
Despite these minor flaws, The History and Physical Examination Workbook: A Common Sense Approach would make a useful adjunct to textbooks on standard history and physical examination for first-year osteopathic medical students. Students in physician assistant and nurse practitioner programs may also benefit from the book. The cases are instructive; the concept of flow for patient histories and physical examinations is appealing in that it reduces the labor of memorization. The use of true stories and osteopathic specialty board questions all add meaningful information to the workbook. Moreover, the addition of the osteopathic perspective throughout the book highlights a valuable approach to the comprehensive patient evaluation. 
 By Mark K. Kauffman, DO, and Michele M. Roth-Kauffman, JD. 287 pp, $34.95. ISBN: 978-0-7637-4340-6. Sudbury, Mass: Jones and Bartlett Publishers; 2007.