History and Physical Exam
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What brings patients to clinicians office?
- Well checks
- New Acute problems
- Continued treatment of an existing problems
- Post operative followup visits
What are the Interview Skills of a clinician?
- Empathetic listener
- Ability to relate to patients of all ages
- Non-judgmental, non-biased interviewing
- Ethnicity and cultural considerations
- Other considerations
What are the parts of a comprehensive health history?
- Identifying data
- Source of history
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Medical History (PMHx)
- Family History (FHx)
- Social History (SocHx)
- Review of Systems (ROS)
What is the detail of the Chief Complaint section?
It is the reason for the visit
What is the detail of the History Present Illness?
- Narrative of why patient is being seen by you
- Document in patient's own words
- Include the seven attributes
What are the 7 attributes of HPI?
- Timing (onset, duration, frequency)
- Factors that aggravate
- Factors that relieve
- Associated symptoms per organ system
What is the parts of the Past Medical History?
- Past Surgical History (PSHx)
- OB/GYN History
- Psychiatric History
What is the Details of the Health Maintenance?
- Allergies to medications and environment
- Side effects to medications
What is the details of the Family History?
- Pedigree with legend
What is the detail of the Social History (SocHx)?
- Personal history - Tobacco, alcohol, illicit drug use
- Spiritual history
What are the details of the Review of Systems?
Per all organ systems
What are the illnesses listed under Childhood Illnesses?
- measles, mumps, rubella
- chicken pox
- whooping cough
- scarlet fever
- Rheumatic fever
- Chronic conditions
What are the illness listed under Adult Health?
- Medical Illnesses
- Surgical Procedures
- Obstetrical History
- Psychiatric History
- Accidents and Injuries
What are the details of the adult surgical procedure?
- Patient’s age at surgery
- Type of procedure
- Dates--Procedure and Hospitalization
- Reaction to anesthesia
What is the detail of the Adult OB history?
- chronological order of pregnancies
- explore each pregnancy
- Type of delivery
- Date of delivery
- Length of gestation
- Condition and weight of infant
What is the details of the Adult Immunization?
- Chicken Pox/Zoster
What is the detail of Adult Health Screen?
- Pap Smear
- Occult Blood
- Cholesterol - Results, When performed
What is the detail of the Adult Allergies?
- Medication, food, insect, environmental
- Patients age and date of reaction
- Cause--name of drug or allergen
- Type of reaction
- Frequency of problem
- Effect on quality of life
What are the components of Health Risk Assessment?
- Diet and exercise
- Sleep patterns
- Drug use
- Environmental hazards
- Safety precautions
- Safe Sex Practices?
- Screen for Domestic Violence
What is the CAGE questionnaire?
- Have you ever felt the need to cut down on your drinking?
- Have you ever felt annoyed at criticism of your drinking?
- Have you ever felt guilty about your drinking
- Have you every had a drink first thing in the morning (eye-opener) for hangover or to steady your nerves
What would you like to do?
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