Health History and Physical Examination Health history is subjective information that the patient tells you. Physical examination is objective information that the examiner uncovers. Although the health history is broken down into sections, there are significant overlaps. Health History (symptoms) 1. Identifying data © Patient identification ~ age, gender, marital status, occupation © Source of history © Source of referral 2. Reliability of the history © Patient’s memory © Patient’s mood © Patient’s trust in physician 3. Chief Complaint © The reason for patient’s visit to the physician, if there are many reasons, determine the order of importance. 4, Present Iliness © Amplifies on the chief complaints © Elicit the seven attributes of the principal symptoms © Timing — onset, duration, frequency © Location — site of complaint, radiation and referrals © Quality — characteristics of the symptom © Quantity — severity (e.g. pain scale 1-10), number of times (e.g. vomiting x 4), amount (vomitus fills bowl) Setting ~ condition under which symptoms occur © Ageravating or relieving factors * What makes symptoms worse *- What makes symptoms better © Associated manifestations = Symptoms that accompany the presenting complaint e.g. nausea and vomiting with chest pain — possible M.I. = Nausea with the headache - migraine. ° © Elicit the patient’s response to the symptoms and elicit the effects the symptoms have on the patient’s lifestyle, © E.g. the pain is so severe that I am unable to walk when it occurs or ©. the pain caused me to miss so many days at work resulting in loss of my job 5. Past History © Childhood illness© —e.g theumatic fever (valvular heart disease), Mumps and Rubelle (infertility) © Adult illness © Medical e.g, diabetes, hypertension, hepatitis, asthma, HIV Surgical — dates, indication, type OBS/GYN ~ para, gravida, menstrual Psychiatric Hospitalizations ~ reason, time confined, treatment 0000 * Health Maintenance o Immunizations © Screening — TB, PAP, Hepatitis, cholesterol, occult blood o Medication © Allergies — medicine, food, insect, environment "= Health records © be aware of HIPPA (confidentiality) . Family History © Specific illness (© hypertension, diabetes, coronary disease, tcholesterol, stroke, seizure, malignancies, suicide, allergies © Age, gender, state of health If deceased ~ age at time of death and cause of death . Personal and Social History Educational level, lifestyle, personal interest, family of origin (be aware of cultural sensitivity). Personality and interest Occupation and job satisfaction Home situation Financial status Sources of support Strengths and fears Coping style Stressful situations Activities of daily living Leisure activities Exercise Diet Life experience such as military Educational level Safety measures such as seat belt use Alternative medicine Smoking and alcohol consumption Sexual practices ec eee rere reese secs8. © Use of illicit drugs Review of systems ° Head to toe. ©. Practice first in this order to avoid omitting areas ‘Elicit pertinent negatives and positives related to chief complaint © General or © Specific for system General Hearing and vision Breathing Digestion and bowel movements ‘Weight changes Sleep pattern Weakness, fatigue, fever General well being eo ecesce Specific Skin, hair, nails Rash Itching Pigmentation Excessive sweating Abnormal hair or nail growth ‘Texture change Head and Neck General © Headache ~ severity, frequency, location © Dizziness, fainting © Loss of consciousness Eyes Vision Blurred vision Double vision (diplopia) Light sensitivity (photophobia) Pain Use of eye medication Trauma Redness Increase eye pressure eee eee eoe