THE HISTORY AND PHYSICAL THE HISTORY THE HISTORY

THE HISTORY AND PHYSICAL THE HISTORY

THE HISTORY • TO REACH A DIAGNOSIS IN ANY PARTICULAR CASE WE MUST FIRST OBTAIN THE PATIENT’S 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.

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.

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

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

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

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 PATIENT’S REASON FOR SEEKING AID. • THE STATEMENT DESCRIBES WHAT BROUGHT THE PATIENT TO THE HOSPITAL. • PITHY PHRASE – “I HAVE A TERRIBLE A HEADACHE”

HISTORY OF PRESENT ILLNESS • THIS IS THE DESCRIPTION OF THE PATIENT’S 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.

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

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

OCCUPATIONAL AND ENVIROMENTAL HISTORY • IT IS IMPORTANT TO INQUIRE ABOUT THE PATIENT’S OCCUPATION SINCE MANY DISEASES HAVE THEIR ORIGIN IN THE WORKPLACE.

BIOGRAPHIC INFORMATION • RACE • SEX • ETHNIC BACKGROUND

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

PSYCHOSOCIAL HISTORY • LEVEL OF EDUCATION • ACCOMPLISHMENTS AND FAILURES DURING THE PATIENT’S LIFE • RELATIONSHIPS

SEXUAL, REPRODUCTIVE AND GYNECOLOGICAL HISTORY • IT IS EXTREMELY IMPORTANT TO BE NONJUDGEMENTAL WHEN OBTAINING THIS PIECE OF THE HISTORY. • SEXUAL PREFERENCE • ABORTIONS • RAPE, ABUSE • MISCARRIAGES • ETC.

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.

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

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