Part 1 History and Physical Assessment
HEALTH HISTORY
Information
Present Illness (PI)
To obtain all details related to the chief complaint
Past history (PH)
To elicit a profile of the individual’s previous illnesses, injuries, or operations
Family Medical History
To identify the presence of genetic traits or diseases that have familial tendencies; to assess family habits and exposure to a communicable disease that may affect family members
Familial diseases, such as heart disease, hypertension, cancer, diabetes mellitus, obesity, congenital anomalies, allergy, asthma, tuberculosis, seizures, sickle cell disease, depression, mental retardation, mental illness or other emotional problems, syphilis, or rheumatic fever; indicate symptoms, treatment, and sequelae.
REVIEW OF SYSTEMS
General—Overall state of health, fatigue, recent and/or unexplained weight gain or loss (period of time for either), contributing factors (change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), frequent infections, general ability to carry out activities of daily living, behavior
Integument—Pruritus, pigment or other color changes, acne, moles, birthmarks, discoloration, eruptions, rashes (location), tendency toward bruising, petechiae, excessive dryness, general texture, disorders or deformities of nails, hair growth or loss, hair color change (for adolescent, use of hair dyes or other potentially toxic substances such as hair straighteners)
Head—Headaches, dizziness, injury (specific details)
Eyes—Visual problems (ask about behaviors indicative of blurred vision, such as bumping into objects, clumsiness, sitting very close to the television, holding a book close to the face, writing with head near desk, squinting, rubbing the eyes, bending the head in an awkward position), cross-eye (strabismus), nystagmus, eye infections, edema of lids, excessive tearing, use of glasses or contact lenses, date of last optic examination
Nose—Nosebleeds (epistaxis), constant or frequent running or stuffy nose, nasal obstruction (difficulty in breathing), alteration or loss of sense of smell
Ears—Earaches, discharge, evidence of hearing loss (ask about behaviors such as need to repeat requests, loud speech, inattentive behavior), results of any previous auditory testing, pulling or rubbing ear
Mouth—Mouth breathing, gum bleeding, toothaches, toothbrushing, use of fluoride, difficulty with teething (symptoms), last visit to dentist (especially if temporary dentition is complete), response to dentist
Throat—Sore throats, difficulty in swallowing, choking (especially when chewing food—may be from poor chewing habits), hoarseness or other voice irregularities
Neck—Pain, limitation of movement, stiffness, difficulty in holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses
Chest—Breast enlargement, discharge, masses, enlarged axillary nodes (for adolescent female, ask about breast self-examination)
Respiratory—Chronic cough, frequent colds (number per year), wheezing, shortness of breath at rest or on exertion, difficulty in breathing, sputum production, infections (pneumonia, tuberculosis), date of last chest x-ray examination, and skin reaction from tuberculin testing
Cardiovascular—Cyanosis or fatigue on exertion, cold extremities, history of heart murmur or rheumatic fever, anemia, date of last blood count, blood type, recent transfusion
Gastrointestinal—nausea, vomiting (not associated with eating, may be indicative of brain tumor or increased intracranial pressure), jaundice or yellowing skin or sclera, belching, flatulence, recent change in bowel habits (blood in stools, change in color, diarrhea, and constipation)
Genitourinary—Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, unpleasant odor to urine, force of stream, discharge, change in size of scrotum, date of last urinalysis (for adolescent, sexually transmitted disease, type of treatment; for male adolescent, ask about testicular selfexamination)
Gynecologic—Menarche, date of last menstrual period, regularity or problems with menstruation, vaginal discharge, pruritus, date and result of last Pap smear (include obstetric history as discussed under birth history when applicable); if sexually active, type of contraception
Musculoskeletal—Weakness, clumsiness, lack of coordination, unusual movements, back or joint stiffness, muscle pains or cramps, abnormal gait, deformity, fractures, serious sprains, activity level, redness, swelling, tenderness
Neurologic—Seizures, tremors, dizziness, loss of memory, general affect, fears, nightmares, speech problems, any unusual habit
Endocrine—Intolerance to weather changes, excessive thirst and urination, excessive sweating, salty taste to skin, signs of early puberty
Lymphatic—History of frequent infections, enlarged lymph nodes in any region, swelling, tenderness, red streaks
SUMMARY OF PHYSICAL ASSESSMENT OF THE NEWBORN
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