THE HISTORY AND PHYSICAL

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THE HISTORY AND PHYSICAL

• THE HISTORY

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THE HISTORY

• TO REACH A DIAGNOSIS IN ANY PARTICULAR CASE WE
  MUST FIRST OBTAIN THE PATIENTS ACCOUNT OF THE
  ILLNESSS I.E. THE HISTORY.
• MANY TIMES WE CAN ESTABLISH A DIAGNOSIS PRIOR TO
  THE EXAMINATION. HOWEVER EVEN THE MOST SKILLED
  CLINICIAN WOULD NEVER NEGLECT A COMPLETE AND
  THOUGHTFUL EXAMINATION.

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THE HISTORY
FEW PATIENTS ARE ABLE TO COMMUNICATE THE
MEDICALLY IMPORTANT FACTS OF THEIR
DISEASE. MOST PATIENTS DESCRIBE MANY IRRELEVANT
FACTS OF THEIR DISEASE. IT IS YOUR RESPONSIBILITY
TO UNCOVER THE PERTINENT FACTS. NEVER MAKE THE
PATIENT FEEL THAT HE OR SHE IS BEING GUIDED OR
UNIMPORTANT. THIS IS ONE OF THE MANY ARTS OF
MEDICINE. THE PATIENT COMPLAINS OF A CHILL. WHAT
MIGHT WE ASK ? NEVER HAVE A PRECONCEIVED
DIAGNOSIS. ALWAYS ESTABLISH YOUR OWN.
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WHAT DOES IT TAKE TO OBTAIN A GOOD HISTORY?

• ONE WHO CARES ABOUT THE PATIENT.
• ONE WHO IS COMPULSIVE.
• ONE WHO MAKES THE PATIENT FEEL COMFORTABLE, NOT
  RUSHED
• A KNOWLEDGE OF PEOPLE
• A KNOWLEDGE OF MEDICINE

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WHAT IS THE FORMAT OF THE HISTORY AND PHYSICAL?

• SOURCE AND RELIABILITY
• CHIEF COMPLAINT
• HISTORY OF PRESENT ILLNESS
• PAST MEDICAL HISTORY
• OCCUPATIONAL AND ENVIROMENTAL HISTORY
• BIOGRAPHIC INFORMATION
• FAMILY HISTORY
• PSYCHOSOCIAL HISTORY
• SEXUAL, REPRODUCTIVE
• REVIEW OF SYMPTOMS
• PHYSICAL EXAM
• LABORATORY DATA
• PROBLEM LIST
• ASSESMENT AND PLAN

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THE HISTORYSOURCE AND RELIABILITY

• YOU SHOULD DOCUMENT THE SOURCE OF YOUR
  INFORMATION
• PATIENT
• FAMILY
• OLD CHART

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CHIEF COMPLAINT

• CONSIDER THIS TO BE THE OPENING STATEMENT OF A
  STORY. WHEN YOU PRESENT THE CASE, THIS LINE WILL
  CLUE THE LISTENER INTO THE PATIENTS REASON FOR
  SEEKING AID.
• THE STATEMENT DESCRIBES WHAT BROUGHT THE PATIENT
  TO THE HOSPITAL.
• PITHY PHRASE I HAVE A TERRIBLE A HEADACHE

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HISTORY OF PRESENT ILLNESS

• THIS IS THE DESCRIPTION OF THE PATIENTS ILLNESS
  AS TOLD BY THE PATIENT, FAMILY, OLD CHART OR A
  COMBINATION OF THESE.
• LIST THE EVENTS IN CHRONOLOGICAL ORDER
• AT TIMES YOU WILL NEED TO MOVE INFORMATION FROM
  THE PAST MEDICAL HISTORY TO THE HPI IF THE
  INFORMATION IS PERTINENT TO THE CURRENT ILLNESS.

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HISTORY OF PRESENT ILLNESS

• WHEN DID THE ILLNESS BEGIN
• MODE OF ONSET
• WHERE
• HOW LONG HAVE THE SYMPTOMS LASTED
• RECURRENT
• CHARACTER
• CHANGES IN CHARACTER
• ADDITIONAL SYMPTOMS

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PAST MEDICAL HISTORY

• GENERAL STATE OF HEALTH
• PAST ILLNESSES
• INJURIES
• HOSPITALIZATIONS
• SURGERY
• ALLERGIES
• IMMUNIZATIONS
• SUBSTANCE ABUSE
• DIET

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OCCUPATIONAL AND ENVIROMENTAL HISTORY

• IT IS IMPORTANT TO INQUIRE ABOUT THE PATIENTS
  OCCUPATION SINCE MANY DISEASES HAVE THEIR ORIGIN
  IN THE WORKPLACE.

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BIOGRAPHIC INFORMATION

• RACE
• SEX
• ETHNIC BACKGROUND

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FAMILY HISTORY

• CLUES TO THE PATIENTS ILLNESS MAY BE FOUND IN
  THE FAMILY HISTORY. IN ADDITION, YOU MAY UNCOVER
  AN INHERITABLE DISEASE WHICH WILL REQUIRE
  COUNSELING OF FAMILY MEMBERS.

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PSYCHOSOCIAL HISTORY

• LEVEL OF EDUCATION
• ACCOMPLISHMENTS AND FAILURES DURING THE PATIENTS
  LIFE
• RELATIONSHIPS

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SEXUAL, REPRODUCTIVE AND GYNECOLOGICAL HISTORY

• IT IS EXTREMELY IMPORTANT TO BE NON-JUDGEMENTAL
  WHEN OBTAINING THIS PIECE OF THE HISTORY.
• SEXUAL PREFERENCE
• ABORTIONS
• RAPE, ABUSE
• MISCARRIAGES
• ETC.

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REVIEW OF SYMPTOMS

• YOU WILL ASK QUESTIONS REGARDING EACH SYSTEM OF
  THE BODY.
• WHY?
• THIS IS A WAY TO CHECK YOUR DATABASE TO THIS
  POINT AND TO IDENTIFY ANY FURTHER PROBLEMS WHICH
  MAY HAVE BEEN OVERLOOKED.

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REVIEW OF SYMPTOMS

• HEAD
• EYES
• EARS
• NOSE
• THROAT
• MOUTH
• CHEST
• HEART
• ABDOMEN
• MUSCULOSKELETAL
• NEUROLOGICAL
• ENDOCRINE
• SKIN

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REVIEW OF SYMPTOMS

• PERTINENT POSITIVES - MAY BE RELATED TO THE
  PRESENT ILLNESS
• PERTINENT NEGATIVES - SYMPTOMS WHICH ARE ABSENT
  BUT MAY HAVE BEEN RELATED TO THE PRESENT ILLNESS
• SEE HPI
• PAGE 23 SWARTZ