History Taking

1. Component of the comprehensive health history
Present illness
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Past history
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Family history
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Social history
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The History and physical examination;
1) comprehensive assessment
Appropriate for new patients in office or hospital
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provides fundamental/personalized knowledge about the patient
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strengthens clinician/patient relationship
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helps identify/rule out physical cause related to patients concerns
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provides a baseline for future assessments
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develops proficiency in essential skills of physical exam
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2) focused assessment
is appropriate for established pts especially during routine or urgent care visits
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addresses focused concerns or symptoms
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assesses symptoms restricted to a specific body system.
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applies exam methods relevant to assessing the concern or problem as thoroughly and carefully as possible
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Differences between subjective and objective data
1) Subjective
What the patient tells you.
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The history, from chief complaint through the review of systems.
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2) Objective
What you detect through exam. (Laboratory information and test data)
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All physical exam findings.
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Components of adult health history
1) Identifying data; Age, gender, occupation, marital status.
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Source of history- usually the patient, but can be family member, friend, letter of referral, medical record
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2) Reliability; Varies according to patient's memory, trust, mood.
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3) Chief Complaint(s); The one or more symptoms causing the patient to seek care.
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4) Present Ilness; Amplifies chief complaint; describes how each symptom developed.
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Includes patient's thoughts and feelings about illness.
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Pulls in relevant portions of review of systems, called "pertinent positives and negatives."
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May include meds, allergies, smoking and alcohol habits.
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5) Past History; Lists childhood illnesses.
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Lists adult illnesses with dates for at least four categories: medical, surgical, ob/gyn and psych.
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Includes health maintenance such as immunizations,screening tests, lifestyle and home safety.
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6) Family history; Outlines age and health, or age and cause of death of siblings, parents and
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grandparents.
7) Personal and Social History; Educational level, family of origin,current household, personal
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interests and lifestyle
8) Review of systems; Documents presence or absence of common symptoms related to each major
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body system

2. Initial Information
1) Date and time of history; especially in urgent, emergent or hospital settings.
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2) identifying data; age, gender, marital status and occupation
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3) reliability; the patient is vague when describing symptoms and the details are confusing.
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Chief Complaint(s)
Patient's direct statement concerning one or more symptoms/concerns that brought them to the hospital at this
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time
response to an open-ended question recorded in their own words (sometimes in quotes)
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Principal symptom
1) location; (2) quality; (3) quantity or severity; (4) timing, including onset, duration, and frequency; (5) the
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setting in which it occurs; (6) factors that have aggravated or relieved the symptom; and (7) associated
manifestations.
Medical History
Medications should be noted, including name, dose, route, and frequency of use
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Allergies
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Alcohol and drug use should always be investigated
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Past History
1) Childhood illnesses: measles, rubella, mumps, fever, Palio
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2) Adult medical History, surgeries, hospitalizations, Psychiatric problems, serious accident/
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injuries, allergies, Medications, Health care maintanence, pertinent childhood illnesses
Specifically ask about: diabetes, hypertension, MI, Stroke, asthma, emphysema, TB, cancer, gall baldder,
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kidney, thyroid disease, anemia, seizure disorder, peptic ulcer disease, arthritis, hepatitis
Family History
Review each of the following conditions and record whether they are present or absent in the family:
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hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease,
arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance
abuse, and allergies
Review of Systems
ROS directly correlates with the associated signs and symptoms documented in the HPI and the CC .
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General: Includes all symptoms that cannot be associated with a body system Chills ,Fever , Weight change
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and Appetite change
Eyes : Eye pain , Eye discharge , Eye redness ,Visual changes
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Head, Ears, Nose, Throat (HENT) ; Facial swelling ,sore throat ,dental pain ,sinus congestion
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Cardiovascular (CV); palpitations, chest pain leg swelling
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Respiratory; coughing ,shortness of breath (SOB) ,wheezing
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Gastrointestinal (GI); Abdominal pain , Nausea ,vomiting ,blood in stool
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Genitourinary (GU) ; urinary frequency ,dysuria ,flank pain ,pelvic pain
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Musculoskeletal (MS); Myalgias ,back pain, joint swelling
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Skin ; laceration ,abscess, rash ,itching
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3. Neurological; do not confuse with psychological dizziness (this should be differentiated between light
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headiness and room spinning headache ,speech changes ,numbness
Psychological; do not confuse with neurological ,depression ,suicidal ideation ,nervous confusion
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the physical examination suggested sequence and positioning
General survey
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Vital signs
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Skin; upper torso anterior and posterior
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Head and neck including thyroid and lymph nodes.
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Nervous system ( mental status, cranial nerves, tone)
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Thorax and lungs
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Breasts
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Abdomen
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Cardiovascular
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Part 2 WIPER
W ash hands (before and after) - wear gloves where appropriate
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I ntroduce yourself to the patient and seek his or her consent
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P osition the patient correctly
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E xpose the patient as needed (e.g.‘Please take off your shirt for me now, if that is allright’)
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R ight side of the bed
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Physical Examination
1. Reflect on your approach to the patient
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2. Adjust the lighting and the environment
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3. Check your equipment
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4. Make the patient comfortable
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5. Observe standard and universal precautions
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6. Choose the sequence, scope, and positioning of examination
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Lighting
Tangential lighting is optimal for inspecting structures such as the jugular venous pulse, the thyroid
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gland, and the apical impulse of the heart
When light is perpendicular to the surface or diffuse, shadows are reduced and subtle undulations across
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the surface are lost
Equipment for the Physical Examination
Ophthalmoscope , Otoscope , A flashlight or penlight
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Tongue depressors , A ruler and a flexible tape measure
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Thermometer , Watch , A stethoscope
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Equipment for the Physical Examination
A visual acuity card, A reflex hammer , Sphygmomanometer
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Common Symptoms:
Fatigue ▪ Weakness ▪ Fever, chills, night sweats ▪ Weight change ▪ Pain
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Fatigue
The most common symptom in clinical medicine
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4. Refers to the subjective human experience of physical and mental weariness, sluggishness, low energy, and
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exhaustion
“I don’t feel like getting up in the morning” . . . “I don’t have any energy” . . . “I can hardly get through the
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5. Weakness
Weakness is a reduction in the power that can be exerted by one or more muscles.
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It must be distinguished from increased fatigability, limitation in function due to pain or articular stiffness, or
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impaired motor activity
Fever, Chills, and Night Sweats
EXPECTED: temperature range of 36.2° C to 37.7° C
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UNEXPECTED: Fever, hypothermia
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Distinguish between feeling cold and a shaking chill with shivering throughout the body and chattering of teeth
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Recurrent shaking chills suggest more extreme swings in temperature and systemic bacteremia
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Night sweats raise concerns about tuberculosis or malignancy
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In immunocompromised patients with sepsis, fever may be absent, low-grade, or drop below normal
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(hypothermia).
Normal Variation in Body Temperature. When evaluating a fever, different normal variations
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must be considered.
Fever in Elderly Individuals. The normal body temperature, as well as the physiological daily
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temperature fluctuation, can be reduced in frail, elderly individuals, although not necessarily in healthy elderly
people.

6. Weigh change
Weight gain occurs when caloric intake exceeds caloric expenditure over time.
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It also may reflect abnormal accumulation of body fluids.
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Weight loss has many causes: decreased food intake, dysphagia, vomiting, and insufficient supplies of
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food; defective absorption of nutrients; increased metabolic requirements; and loss of nutrients through the
urine, feces, or injured skin. Be alert for signs of malnutrition.
Weigh change: medications
1) Drugs associated with weight loss:
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Anticonvulsants, Antidepressants (serotonin), Levodopa, Digoxin, Thyroid medication,
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2) Drugs associated with weight gain;
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Tricyclic antidepressants ▪ Insulin and sulfonylurea ▪ Contraceptives ▪ Glucocorticoids ▪ Progestational steroids
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Acute and Chronic Pain
Acute; Usually has a sudden onset as a result of an identifiable tissue injury, such as surgery, inflammation,
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or traumatic injury.
Chronic: Is pain that lasts beyond the expected time of healing, usually for at least 6 months;
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7. General Appearance
Apparent State of Health
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Level of Consciousness
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Signs of Distress
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Skin Color and Obvious Lesions
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Dress, Grooming, and Personal Hygiene
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Facial Expression
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Odors of the Body and Breath
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Height and Weight: Stature
▪ Short stature
▪ General nutritional state or
▪ Significant illness during childhood
▪ Turner syndrome, childhood renal failure, and
▪ Achondroplastic and hypopituitary dwarfism
▪ Heigh loss: osteoporosis and vertebral compression fractures
Tall stature
▪ Familial
▪ Marfan’s syndrome
▪ Prepubertal hypogonadism and Gigantism
Vital signs
Blood pressure
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Heart rate
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Respiratory rate
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Temperature
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