Patient History & Physical

CC

HPI
Cardinal features of sx’s:
1. location and radiation
• precise location
• deep or superficial
• localized or diffuse
2. quality
• usual descriptors
• unusual descriptors
3. quantification
• type of onset
• intensity or severity (scale of 1 to 10)
• impairment or disability
• numeric description  number of events, size, volume
4. chronology
• time of onset and intervals b/t recurrences
• duration of sx
• periodicity and frequency of sx
• course of sx  short-term/long-term
5. setting
6. modifying factors
• precipitating and aggravating factors
• palliating factors
7. associated sx’s
Relevant sx’s in same body system (focused ROS)
Relevant sx’s in other body systems
Relevant non-sx data (secondary info)

PMH
Medical issues, surgeries, hospitalizations, ER visits – when& why, pregnancies
Medications  dosages, route of admin., OTC, supplements
~ ask about BCP’s, hormones, laxatives, vitamins
Allergies  medications, foods, environmental

SocHx
Habits
• caffeine
• tobacco  forms, pack years
• alcohol  type, amt. at once/daily/wkly, CAGE Q’s (yes to 2+ = alcohol abuse)
~ have you thought about cutting back?
~ have you gotten annoyed when others talk about your drinking?
~ have you ever felt guilty about your drinking?
~ do you ever have a drink 1st thing in the morning? (eye opener)
• drug use  “street” drugs, illicit use of Rx drugs, amt. at once/daily/wkly
• diet
• exercise
• functional status
• safety  seatbelt, helmet, smoke detectors, guns
• occupation  occupational exposures
• home life (“who lives at home w/ you?”)
• relationships, support systems
• sexuality 
~ do you have sex w/ men, women, or both?
 ~ do you have sex w/ people at risk for STI’s? (drug users, prostitutes)
~ do you use protection? what do you use? every time?
~ have you ever been dx’d w/ an STI?
~ do you have any concerns about your sexual health?
~ any recent changes or probs. in your sexual fxning? men – probs. having or maintaining an
erection? women – pain during intercourse?
• stress
• sprituality/religion
• domestic partner violence/abuse
~ have you ever been hit, slapped, kicked or physically hurt by someone?
~ has anyone ever forced you to have sex?

FamHx
Age and health or cause of death of parents, siblings, grandparents, and kids
Ask about:
• diabetes • weight problems • HTN • tobacco use
• TB • cancer • heart disease • alcoholism
• anemia • stroke • high cholesterol • mental illness
• bleeding problems • kidney disease • asthma

ROS
Symptoms not elicited earlier in interview
~ try to identify symptoms that cause significant problems for pt.