Physical Diagnosis: Methods of Physical Exams Flashcards
Comprehensive Health History
Source History Chief Complaint Present Illness Past History Family History Personal and Social History Review of Systems
General Data
Name, Sex, Religion, Age, Nationality, DOB, POB, occupation, marital status
Source of Information
usually by the companion from friend or family
Reliability
varies according to the patients memory, trust, memory and condition
Chief Complaint
Reason why the patient goes to you
one or more symptoms or concerns causing the patient to seek care
make every attemp to quote the patients own words
ex: Sumasakit po tiyan ko
History of Present Illness (HPI)
Main part of medical history
Main history; main problem
Pulls relevant portion of the ROS
should include pertinent positive and negative
Past History
childhood illnesses
adult illnesses (diabetes, hypertension, asthma HIV, etc)
surgical history
blood transfusion
allergy
gynecologic history (menarche, menopause, sexual history, etc)
psychiatric
Family History
major health or genetic disorders in the patient’s immediate and extended family
drawing a family tree called “genogram or pedigree”
causes of death
Personal and History
smoking, alcohol consumption, healthcare, social circumstances, illegal issues
how many per day, how long, how many days
type of alcohol, frequency per week
Personal and Social History
sleeping pattern, exercise and diet
safety measures
vices and addiction
alternative health care practices
Review of Systems (ROS)
documents presence or absence of common symptoms related to each major body system
