Comprehensive History and Physical Chapter 2 1 Objectives

Comprehensive History and Physical Chapter 2 1

Objectives § Discuss the importance of a well-documented comprehensive history and physical (H&P) § Describe how the comprehensive H&P may be adapted for various medical disciplines and practice settings § Identify components of a comprehensive H&P 2

The Comprehensive H&P § Often used as the basis for the entire course of medical management for a patient § Failure to adequately obtain and document a thorough H&P may lead to inadequate care of the patient § Usually obtained when a patient presents to a particular setting for the first time, or when a patient is hospitalized § History usually the most important aspect of establishing a diagnosis 3

Modifications of the H&P § Comprehensive H&P modified for interval (or follow-up) and health maintenance visits § Medical specialties and practice settings § Acuity of patient presentation § Age of patient 4

Chief Complaint and History of Present Illness § Patient identification § Chief complaint 5

Chief Complaint and History of Present Illness § History of present illness (HPI) or chief complaint (HCC) § § § § Location Timing and duration Quality Context Severity Modifying factors Associated signs and symptoms 6

Past Medical History § Past medical history Medical Surgical Hospitalizations Medications: prescription, OTC, herbal, supplements, etc. § Allergies to drugs or foods (not environmental) § Health maintenance § Immunizations § § 7

Family History § Health history of first-degree relatives: parents, grandparents, siblings, children • If deceased, age at death and cause of death • Screening for genetically predisposed conditions, such as cardiovascular disease, diabetes, cancer, endocrine disorders, mental illness, substance abuse, etc. 8

Psychosocial History § Identify factors outside of past or current medical conditions that may influence the patient’s overall health § § § Education Family unit and living situation Occupation Health literacy Sexual orientation Religious and cultural beliefs 9

Psychosocial History § Behaviors that create risk factors for specific conditions Tobacco use Alcohol use Drug use Safety habits, such as use of seatbelts and protective gear § Nutrition § Exercise § Access to and ability to pay for health care § § 10

Review of Systems § Inventory of body systems designed to document symptoms which the patient may be experiencing or has experienced, which may or may not be related to the HPI § Usually limited to a specific time frame, rather than open ended § Positive symptoms: symptoms patient has had or is now having § Negative symptoms: symptoms patient is not having or has not had 11

CMS Identified Systems • Constitutional • Musculoskeletal • Eyes • Integumentary • Ears, Nose, Throat • Neurological • Cardiovascular • Psychiatric • Respiratory • Endocrine • Gastrointestinal • Hematologic • Genitourinary • Allergic/Immunologic

The Physical Examination § Range of normal findings associated with good health § Findings outside of the normal range may correlate with specific abnormal states or diseases § Both positive and negative findings may be pertinent § Generally conducted in head-to-toe order, with painful or invasive components done last 13

Documenting the Physical Exam § By system or body region, similar to ROS systems but with slight modification § General § Breasts § Vital signs § Abdomen § Skin § Male GU, female GU/GYN § HEENT § Rectal § Neck § Musculoskeletal § Respiratory § Neurologic § Cardiovascular § Sometimes joined as “chest” and may include breasts

Lab and Diagnostic Studies § Rationale for ordering studies should be supported by the history and physical exam § Documenting actual values, rather than an interpretation (i. e. , “normal”), makes it easier to trend values over time § Allows other readers to make their own interpretation of the data 15

Differential Diagnoses (DDx) § Differential diagnoses (DDx) is a list of possible explanations for the symptoms the patient presents with § The more broad the DDx, the more likely you are to reach the most likely or correct diagnoses § Generate DDx based on CC alone, and continually refine and reorder based on information from the H&P, diagnostic studies, etc. 16

Differential Diagnoses (DDx) § May be a symptom or finding, rather than an actual diagnosis § May not reach a definitive diagnosis at each encounter; it may take a series of encounters to fully evaluate a complaint and reach a diagnosis § One DDx may be most likely, but you may need to rule out other DDx because of the potential outcomes if a diagnosis is missed 17

Assessment § Based on evaluation of all the data available, the most likely diagnosis § An assessment involves critically thinking about DDx and rationale of why one is more likely than another § Example: chest pain, most likely musculoskeletal in nature, as no history of CVD risk factors; pain exacerbated by certain movements; and no diaphoresis, nausea, or difficulty breathing 18

Plan Additional studies or work-up needed Referrals or consultations needed Pharmacological management Non-pharmacological or other management (e. g. , physical therapy) § Patient education § Disposition § § 19

Points to Ponder § What might happen if the differential diagnoses are narrowed too quickly? § Consider what ROS would be indicated for a 30 -year-old woman who presents with abdominal pain. How would the ROS differ if the patient were 70? If the patient were male? § Do you believe there is an over-reliance on diagnostic tests? 20

Credits Publisher: Margaret Biblis Senior Acquisitions Editor: Andy Mc. Phee Developmental Editors: Nancy Hoffmann, Stephanie Rukowicz Production Manager: Sharon Lee Manager of Electronic Product Development: Kirk Pedrick Electronic Publishing: Sandra Glennie The publisher is not responsible for errors of omission or for consequences from application of information in this presentation, and makes no warranty, expressed or implied, in regard to its content. Any practice described in this presentation should be applied by the reader in accordance with professional standards of care used with regard to the unique circumstances that may apply in each situation.