OM301 

◦The health history

◦The physical examination

◦The written record

Symptom:

Symptoms are subjective and experienced only by the patient.

For example, pain, fatigue, shortness of breath, and a rash are all symptoms. They’re the feelings, sensations, and changes in health that a person notices. 

Signs：

A sign is objective evidence of disease that another person can detect, often a healthcare professional. For example, a doctor might observe a rash, a swollen joint, or a fever when examining a patient. 

THE HEALTH HISTORY: STRUCTURE AND PURPOSES

🞂Chief Complaint(s)

🞂Present Illness

🞂Past History

🞂Family History,

🞂Personal and Social History

🞂Review of Systems

Chief complaint：

The one or more symptoms or concerns causing the patient to seek care

🞂Make every attempt to quote the patient’s own words.

🞂For example, “My stomach hurts and I feel awful.” Sometimes patients have no overt complaints, in which case you should report their goals instead. For example, “I have come for my regular checkup”; or “I’ve been admitted for a thorough evaluation of my heart.”

History of present illness

- Amplifies the Chief Complaint, describes how each symptom developed

Includes patient’s thoughts and feelings about the illness.

• This section of the history is a complete, clear, and chronologic account of the problems prompting the patient to seek care. 
• The narrative should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatments.
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  • The principal symptoms should be well-characterized, with descriptions of 
  • (1) location
  • (2) quality
  • (3) quantity(amount) or severity 
  • (4) timing, including onset, duration, and frequency
  • (5) the setting in which they occur
  • (6) factors that have aggravated or relieved the symptoms
  • (7) associated manifestations

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  Past History

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  • Childhood Illnesses:

  • such as measles, rubella风疹 , mumps, whooping cough, chicken pox, rheumatic fever, scarlet fever, and polio are included in the Past History. 
  • Also included are any chronic childhood illnesses.
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  • Adult Illnesses in each of four areas:

    • Medical (such as diabetes, hypertension, hepatitis, asthma, HIV disease, information about hospitalizations); 
    • Surgical (include dates, indications, and types of operations); 
    • Obstetric/gynecologic (relate obstetric history, menstrual history, birth control, and sexual function); 
    • Psychiatric (include dates, diagnoses, hospitalizations, and treatments).

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    Family History

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    • Outline or diagram the age and health, or age and cause of death, of each immediate relative, including parents, grandparents, sib-lings(sisters, brothers), children, and grandchildren. 
    • Review each of the following conditions and record if they are present or absent in the family: hypertension, coronary artery disease, stroke, diabetes, thyroid or renal disease, cancer (specify type), arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, alcohol or drug addiction, and allergies, as well as symptoms reported by the patient.
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    Personal and Social History

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    • occupation;
    • home situation and significant others; sources of stress, both recent and long-term; important life experiences, job history, financial situation, and retirement; 
    • lifestyle habits that promote health or create risk such as exercise and diet, dietary supplements or restrictions, and use of coffee, tea, and other caffeine-containing beverages. 
    • You may want to include any alternative health care practices.

Review of Systems

• Think about asking series of questions going from “head to toe.” 
• Start with a fairly general question as you address each of the different systems. This focuses the patient’s attention and allows you to shift to more specific questions about systems that may be of concern. Examples of starting questions are: “How are your ears and hearing?” “How about your lungs and breathing?” “Any trouble with your heart?” “How is your digestion?” “How about your bowels?” 
• Keep your technique flexible.
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• General. 

• Usual weight, recent weight change, any clothes that fit more tightly or loosely than before. Weakness, fatigue, fever.

• Skin. Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails.

• Head: Headache, head injury, dizziness, lightheadedness.
• Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts.
• Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids.
• Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble.
• Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness.
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• Neck. Lumps, “swollen glands,” goiter, pain, or stiffness in the neck.
  
  Breasts. Lumps, pain or discomfort, nipple discharge, self-examination practices.

• Respiratory. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis.

• Cardiovascular. Heart trouble, high blood pressure, heart murmurs, chest pain or discomfort, palpitations, dyspnea, edema, past electrocardiographic or other heart test results.

• Gastrointestinal. 
• Trouble swallowing, heartburn, appetite, nausea, bowel movements, color and size of stools, change in bowel habits, rectal bleeding or black stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis.
• Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, incontinence
  

• Genital. 
• Male: Hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually transmitted diseases and their treatments. Sexual habits, interest, function, satisfaction, Exposure to HIV infection.
• Female: Age at menarche; regularity, frequency, and duration of periods; amount of bleeding, bleeding between periods, last menstrual period; dysmenorrhea, PMS; age at menopause, menopausal symptoms, postmenopausal bleeding. Vaginal discharge, itching, sores. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced); complications of pregnancy; birth control methods. Exposure to HIV infection.

• Peripheral Vascular. leg cramps, varicose veins, past clots in the veins.

• Musculoskeletal. 
  • Muscle or joint pains, stiffness, arthritis, gout, and backache.
  • If present, describe location of affected joints or muscles, presence of any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (for example, morning or evening), duration, and any history of trauma.
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• Neurologic. 
  • Fainting, seizures, weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles,” tremors or other involuntary movements.

• Hematologic. 
  • Anemia, easy bruising or bleeding, past transfusions and/or transfusion reactions.

• Endocrine. 
• Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria.

• Psychiatric. 
• Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant.

General Survey. Observe the patient’s general state of health, height, build, and sexual development. Note posture, motor activity, and gait; dress, and any odors of the body or breath. Watch the patient’s facial expressions and note manner, affect, and reactions to persons and things in the environment. Listen to the patient’s manner of speaking.

Vital Signs. Measure the blood pressure. Count the pulse and respiratory rate. measure the body temperature.

Skin. Observe the skin of the face and its characteristics. Identify any lesions, noting their location, distribution, arrangement, type, and color. Inspect and palpate the hair and nails.

Head, Eyes, Ears, Nose, Throat：

• Head: Examine the hair, scalp, skull, and face. 
• Eyes: Check visual and screen the visual fields. Observe the eyelids and inspect the sclera and conjunctiva of each eye. inspect each cornea, iris, and lens. Compare the pupils, and test their reactions to light. Assess the extraocular movements. 
• Ears: Inspect the auricles, canals, and drums. Check auditory acuity.
• Nose and sinuses: Examine the external nose; using a light and a nasal speculum, inspect the nasal mucosa, septum, and palpate for tenderness of the frontal and maxillary sinuses. 
• Throat: Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx.

Neck. Inspect and palpate the cervical lymph nodes. Note any masses or unusual pulsations in the neck. Feel for any deviation of the trachea. Observe sound and effort of the patient’s breathing. Inspect and palpate the thyroid gland.

Back:

Inspect and palpate the spine and muscles of the back.

Posterior Thorax and Lungs. Inspect and palpate the spine and muscles of the upper back. Inspect, palpate, and percuss the chest. Identify the level of diaphragmatic dullness on each side. Listen to the breath sounds; identify any adventitious (or added) sounds, and, if indicated, listen to the transmitted voice sounds

Breasts, Axillae, and Epitrochlear Nodes. 

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  • In a woman, inspect the breasts with her arms relaxed, then elevated, and then with her hands pressed on her hips.
  •  In either sex, inspect the axillae and feel for the axillary nodes. 

Anterior Thorax and Lungs. Inspect, palpate, and percuss the chest. Listen to the breath sounds, any adventitious sounds, and, if indicated, transmitted voice sounds.

Cardiovascular System:

Inspect, palpate and percuss  the precordium. Note the location, diameter, amplitude振幅, and duration of the apical impulse. Listen (auscultate)  at the apex and the lower sternal border with the bell of a stethoscope. Listen at each auscultatory听诊的area with the diaphragm. Listen for the first and second heart sounds, and for physiologic splitting of the second heart sound. Listen for any abnormal heart sounds or murmurs.

Abdomen:

Inspect, palpate, percuss and auscultate, the abdomen. Palpate lightly, then deeply. Assess the liver and spleen by percussion and then palpation. If you suspect kidney infection, percuss posteriorly over the costovertebral angles.

Lower Extremities. Examine the legs, assessing three systems

Examination with the patient supine 仰卧

• Peripheral Vascular System. Palpate the inguinal lymph nodes. Inspect for lower extremity edema, discoloration, or ulcers. Palpate for pitting edema.
•  Musculoskeletal System. Note any deformities or enlarged joints. If indicated, palpate the joints, check their range of motion.
•  Nervous System. Assess lower extremity muscle bulk, tone, and strength; also sensation and reflexes. Observe any abnormal movements.

• Examination with the patient standing
• Peripheral Vascular System. Inspect for varicose veins.  
• Musculoskeletal System. Examine the alignment of the spine and its range of motion, the alignment of the legs, and the feet.
•  Genitalia and Hernias in Men. Examine the penis and scrotal contents and check for hernias.

 Nervous System. Observe the patient’s gait and ability to walk heel-to-toe, walk on the toes, walk on the heels.

Nervous System:

The complete examination of the nervous system can also be done at the end of the examination. It consists of the five segments described below: mental status, cranial nerves, motor system, sensory system, and reflexes.

Mental Status. assess the patient’s orientation, mood, thought process, thought content, abnormal perceptions, insight and judgment, memory and attention, information and vocabulary, calculating abilities, abstract thinking, and constructional ability.

• Cranial Nerves. check sense of smell, strength of the temporal and masseter muscles, corneal reflexes, facial movements.

• Motor System. Muscle bulk, tone, and strength of major muscle groups. 

• Sensory System. Pain, temperature, light touch, vibration, and discrimination. Compare right with left sides and distal with proximal areas on the limbs. 

Reflexes. Including biceps, triceps, brachioradialis, patellar, Achilles deep tendon reflexes.

RECORDING YOUR FINDINGS

Now you are ready to review an actual written record documenting a patient’s history and physical findings,

Your written record organizes the information from the history and physical examination and should clearly communicate the patient’s clinical issues to all members of the health care team.

4. Consciousness

5. Tone of Voice

6. Facial Expression

7. The position in bed (Active position,Passive  position,Compulsive position)

8. Posture and gait.