1: Overview: Physical Examination and History Taking

Overview: Physical Examination and History Taking

This chapter provides a road map to clinical proficiency in two critical areas: the health history and the physical examination.

For adults, the comprehensive history includes Identifying Data and Source of the History, Chief Complaint(s), Present Illness, Past History, Family History, Personal and Social History, and Review of Systems. New patients in the office or hospital merit a comprehensive health history; however, in many situations, a more flexible focused, or problem-oriented, interview is appropriate. The components of the comprehensive health history structure the patient’s story and the format of your written record, but the order shown below should not dictate the sequence of the interview. The interview is more fluid and should follow the patient’s leads and cues, as described in Chapter 3.