Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 1. The History

BUILDING THE HISTORY

The following outline of a patient history is a guideline and should not be considered a rigid structure. You are beginning your relationship with the patient at this point. Take care with this relationship. The information you gain in the history loses meaning if your bond with the patient is less than strong. Choose a comfortable setting and help the patient get settled. Maintain eye contact and use a conversational tone. Begin by introducing yourself and explaining your role. Help the patient understand why you are building the history and how it will be used. Explore positive responses with additional questions: Where, when, what, how, and why. Be sensitive to the patient’s emotions at all times. Avoid confrontation and asking leading questions.

CHIEF COMPLAINT

Problem or symptom: Reason for visit

Duration of problem

Patient information: Age, sex, marital status, previous hospital admissions; occupation

Other complaints: Secondary issues, fears, concerns, what made patient seek care

Always consider why this particular problem may be affecting this particular patient at this time. Why did this patient succumb to a risk or an exposure when others similarly exposed did not?

PRESENT PROBLEM

Chronologic ordering: Sequence of events patient has experienced

State of health just before onset of present problem

Complete description of first symptom: Time and date of onset, location, movement

Possible exposure to infection or toxic agents

If symptoms are intermittent, describe typical attack: Onset, duration, symptoms, variations, inciting factors, exacerbating factors, relieving factors

Effect of illness: On lifestyle, on ability to function; limitations imposed by illness

“Stability” of problem: Intensity, variations, improvement, worsening, staying same

Immediate reason for seeking attention, particularly for long-standing problem

Review of appropriate system when there is a conspicuous disturbance of a particular organ or system

Medications: Current and recent, dosage of prescriptions, home remedies, nonprescription medications

Review of chronology of events for each problem: Patient’s confirmations and corrections

MEDICAL HISTORY

GENERAL HEALTH AND STRENGTH

Childhood illnesses: Measles, mumps, whooping cough, chickenpox, smallpox, scarlet fever, acute rheumatic fever, diphtheria, poliomyelitis

Major adult illnesses: Tuberculosis (TB), hepatitis, diabetes, hypertension, myocardial infarction, tropical or parasitic diseases, other infections, any nonsurgical hospital admissions

Immunizations: Poliomyelitis, diphtheria, pertussis, tetanus toxoid, influenza, Haemophilus influenzae B, pneumococcal, cholera, typhus, typhoid, bacille Calmette-Guérin (BCG), hepatitis B virus (HBV), last purified protein derivative (PPD) or other skin tests; unusual reactions to immunizations; tetanus or other antitoxin made with horse serum

Surgery: Dates, hospital, diagnosis, complications

Serious injuries: Resulting disability (document fully for injuries with possible legal implications)

Limitation of ability to function as desired as a result of past events

Medications: Past, current, recent medications; dosage of prescription; home remedies and nonprescription medications, particularly complementary and alternative therapies

Allergies: Especially to medications but also to environmental allergens and foods

Transfusions: Reactions, date, number of units transfused

Emotional status: Mood disorders, psychiatric treatment

Children: Birth, developmental milestones, childhood diseases, immunizations

FAMILY HISTORY

The genetic basis for a patient’s response to risk or exposure may determine whether the patient becomes ill when others do not.

Relatives with similar illness

Immediate family: Ethnicity, health, cause of and age at death

History of disease: Heart disease, high blood pressure, hypercholesterolemia, cancer, TB, stroke, epilepsy, diabetes, gout, kidney disease, thyroid disease, asthma and other allergic states, forms of arthritis, blood diseases, sexually transmitted diseases, other familial diseases

Spouse and children: Age, health

Hereditary disease: History of grandparents, aunts, uncles, siblings, cousins; consanguinity

PERSONAL AND SOCIAL HISTORY

Personal status: Birthplace, where raised, home environment; parental divorce or separation, socioeconomic class, cultural background, education, position in family, marital status, general life satisfaction, hobbies and interests, sources of stress and strain

Habits: Nutrition and diet; regularity and patterns of eating and sleeping; exercise: quantity and type; quantity of coffee, tea, tobacco, alcohol; illicit and/or recreational drug use: frequency, type, amount; breast or testicular self-examination

Sexual history: Concerns with sexual feelings and performance, frequency of intercourse, ability to achieve orgasm, number and gender of partners

Home conditions: Housing, economic condition, type of health insurance if any, pets and their health

Occupation: Description of usual work and present work if different; list of job changes; work conditions and hours; physical and mental strain; duration of employment; present and past exposure to heat and cold, industrial toxins (especially lead, arsenic, chromium, asbestos, beryllium, poisonous gases, benzene, and polyvinyl chloride or other carcinogens and teratogens); any protective devices required, for example, goggles or masks

Environment: Travel and other exposure to contagious diseases, residence in tropics, water and milk supply, other sources of infection if applicable

Military record: Dates and geographic area of assignments

Complementary and alternative health and medical systems: History and current use

Religious preference: Religious proscriptions concerning medical care

Cost of care: Resources available to patient, financial worries, candid discussion of issues

REVIEW OF SYSTEMS

It is unlikely that all questions in each system will be asked on every occasion. The following questions are among those that should be asked, particularly at the first interview.

General constitutional symptoms: Fever, chills, malaise, fatigability, night sweats, weight (average, preferred, present, change)

Skin, hair, nails: Rash or eruption, itching, pigmentation or texture change, excessive sweating, abnormal nail or hair growth

Head and neck:

General: Frequent or unusual headaches, their location, dizziness, syncope, severe head injuries, periods of loss of consciousness (momentary or prolonged)

Eyes: Visual acuity, blurring, diplopia, photophobia, pain, recent change in appearance or vision, glaucoma, use of eyedrops or other eye medications, history of trauma or familial eye disease

Ears: Hearing loss, pain, discharge, tinnitus, vertigo

Nose: Sense of smell, frequency of colds, obstruction, epistaxis, postnasal discharge, sinus pain

Throat and mouth: Hoarseness or change in voice, frequent sore throats, bleeding or swelling of gums, recent tooth abscesses or extractions, soreness of tongue or buccal mucosa, ulcers, disturbance of taste

Lymph nodes: Enlargement, tenderness, suppuration

Chest and lungs: Pain related to respiration, dyspnea, cyanosis, wheezing, cough, sputum (character and quantity), hemoptysis, night sweats, exposure to TB, date and result of last chest x-ray examination

Breasts: Pain, tenderness, discharge, lumps, galactorrhea, mammograms (screening or diagnostic), frequency of self-examination

Heart and blood vessels: Chest pain or distress, precipitating causes, timing and duration, character, relieving factors, palpitations, dyspnea, orthopnea (number of pillows needed), edema, claudication, hypertension, previous myocardial infarction, estimate of exercise tolerance, past electrocardiogram (ECG) or other cardiac tests

Peripheral vasculature: Claudication (frequency, severity), tendency to bruise or bleed, thromboses, thrombophlebitis

Hematologic: Any known abnormality of blood cells, transfusions

Gastrointestinal: Appetite, digestion, intolerance of any class of foods, dysphagia, heartburn, nausea, vomiting, hematemesis; regularity of bowels, constipation, diarrhea, change in stool color or contents (clay colored, tarry, fresh blood, mucus, undigested food), flatulence, hemorrhoids; hepatitis, jaundice, dark urine; history of ulcer, gallstones, polyps, tumor; previous x-ray examinations (where, when, findings)

Diet: Appetite, likes and dislikes, restrictions (e.g., because of religion, allergy, or other disease), vitamins and other supplements, use of caffeine-containing beverages (e.g., coffee, tea, cola), an hour-by-hour detailing of food and liquid intake—sometimes a written diary covering several days of intake may be necessary

Endocrine: Thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, diabetes, polydipsia, polyuria, changes in facial or body hair, increased hat and glove size, skin striae

Females:

Menses: Onset, regularity, duration and amount of flow, dysmenorrhea, date of last menstrual period (LMP), intermenstrual discharge or bleeding, itching, date of last Pap smear, age at menopause, libido, frequency of intercourse, sexual difficulties, infertility

Pregnancies: Number, living children, multiple births, miscarriages, abortions, duration of pregnancies, type of delivery for each, any complications during any pregnancy or postpartum period or with neonate, use of oral or other contraceptives, difficulty in getting pregnant

Males: Puberty onset, difficulty with erections, emissions, testicular pain, libido, infertility

Genitourinary: Dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss in force of stream, passage of stone, edema of face, stress incontinence, hernias, sexually transmitted disease (inquire type and symptoms and results of serologic test for syphilis [STS], if known)

Musculoskeletal: Joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity

Neurologic: Syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory

Psychiatric: Depression, mood changes, difficulty concentrating, nervousness, tension, suicidal thoughts, irritability, sleep disturbances

CONCLUDING QUESTIONS

In conclusion, ask:

Is there anything else that you think would be important for me to know?

If there are several problems: Which concerns you the most?

If the history is vague, complicated, or contradictory: What do you think is the matter with you, or, what worries you the most?

Pediatric Variations

BUILDING THE HISTORY

These are only guidelines; you are free to modify and add as the needs of your patients and your judgment dictate.

CHIEF COMPLAINT

A parent or other responsible adult will generally be the major resource. When age permits, however, the child should be involved as much as possible. Remember that every chief complaint has the potential of an underlying concern. What really led to the visit to you? Was it just the sore throat?

RELIABILITY

Note relationship to patient of person who is the resource for history, and record your impression of the competence of that person as a historian.

PRESENT PROBLEM

Be sure to give a clear chronologic sequence to the story.

MEDICAL HISTORY

In general, the age of the patient and the nature of the problem will guide your approach. Clearly, in a continuing relationship much of what is to be known will already have been recorded. Certainly, different aspects of the history require varying emphasis depending on the nature of the immediate problem. There are specifics that will command attention.

Pregnancy/mother’s health:

Infectious disease; give approximate gestational month

Weight gain/edema

Hypertension

Proteinuria

Bleeding; approximate time

Eclampsia, threat of eclampsia

Special or unusual diet or dietary practices

Medications (hormones, vitamins)

Quality of fetal movements, time of onset

Radiation exposure

Prenatal care/consistency

Birth and perinatal experience:

Duration of pregnancy

Delivery site

Labor: Spontaneous/induced, duration, anesthesia, complications

Delivery: Presentation; forceps/spontaneous; complications

Condition at birth: Time of onset of cry; Apgar scores, if available

Birth weight and, if available, length and head circumference

Neonatal period:

Hospital experience: Length of stay, feeding experience, oxygen needs, vigor, color (jaundice, cyanosis), cry. Did baby go home with mother?

First month of life: Color (jaundice), feeding, vigor, any suggestion of illness or untoward event

Feeding:

Bottle or breast: Any changes and why; type of formula, amounts offered/taken, feeding frequency; weight gain

Present diet and appetite: Introduction of solids, current routine and frequency, age weaned from bottle or breast, daily intake of milk, food preferences, ability to feed self; elaborate on any feeding problems

DEVELOPMENT

Guidelines suggested in Chapter 21, Age-Specific Examination: Infants, Children, and Adolescents, are complementary to the milestones listed below. Those included here are commonly used, often remembered, and often recorded in “baby books.” Photographs also may occasionally be of some help. note: It is important to define the growth and developmental status of each child regardless of the particular complaint. That status will inform your understanding of the child, and of the particular problem, and will facilitate the institution of a management plan.

Age when:

Held head erect while held in sitting position

Sat alone, unsupported

Walked alone

Talked in sentences

Toilet trained

School: Grade, performance, learning and social problems

Dentition: Ages for first teeth, loss of deciduous teeth, first permanent teeth

Growth: Height and weight at different ages, changes in rate of growth or weight gain or loss

Sexual: Present status (e.g., in female, time of breast development, nipples, pubic hair, description of menses; in males, development of pubic hair, voice change, acne, emissions). Follow Tanner guides

FAMILY HISTORY

Maternal gestational history: All pregnancies with status of each, including date, age, cause of death of all deceased siblings, and dates and duration of pregnancy in the case of miscarriages; mother’s health during pregnancy

Age of parents at birth of patient

Are parents related to each other in any way?

PERSONAL AND SOCIAL HISTORY

Personal status:

School adjustment

Nail biting

Thumb sucking

Breath-holding

Temper tantrums

Pica

Tics

Rituals

Home conditions:

Parental occupation(s)

Principal caretaker(s) of patient

Food preparation, routine, family preferences (e.g., vegetarianism), who does preparing

Adequacy of clothing

Dependency on relief or social agencies

Number of persons and rooms in house or apartment

Sleeping routines and sleep arrangements for child

REVIEW OF SYSTEMS (SOME SUGGESTED ADDITIONAL QUESTIONS OR PARTICULAR CONCERNS)

Ears: Otitis media (frequency, laterality)

Nose: Snoring, mouth breathing

Teeth: Dental care

Genitourinary: Nature of urinary stream, forceful or a dribble

Skin, hair, nails: Eczema or seborrhoea