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Medical History and Physical
Examination Overview
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Website: http://www.imhotepvirtualmedsch.com/medical-history-and-
physicial-examination.php
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Medical History and Physical
Examination Overview
Companion Online Folder:
IVMS-Physical Diagnosis Notes PowerPoints and Reference Resources
Prepared and presented by:
Marc Imhotep Cray, M.D.
Basic Medical Sciences Teacherhttp://www.imhotepvirtualmedsch.com/
http://www.scribd.com/collections/4219078/IVMS-INTRO-TO-CLINICAL-MEDICINE-e-Notes-and-PowerPointshttp://www.scribd.com/drimhotep_IVMShttp://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/http://www.scribd.com/drimhotep_IVMShttp://www.scribd.com/collections/4219078/IVMS-INTRO-TO-CLINICAL-MEDICINE-e-Notes-and-PowerPointshttp://www.scribd.com/collections/4219078/IVMS-INTRO-TO-CLINICAL-MEDICINE-e-Notes-and-PowerPointshttp://www.scribd.com/collections/4219078/IVMS-INTRO-TO-CLINICAL-MEDICINE-e-Notes-and-PowerPointshttp://www.imhotepvirtualmedsch.com/ -
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COMPONENTS OF THE MEDICAL
HISTORY
Identifying Data (ID)
Chief Complaint (CC)
History of Present Illness (HPI)
Past Medical History (PMH)
Current Health Status (CHS)
Psycho Social History (PSH)
Family History (FH)
Review of Systems (ROS)
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Identifying Data (ID)
Name or initials
Date of birth
Medical record number
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Chief Complaint (CC)
One-liner--why patient here--use patient's own
words
How to write--patients age, occupation or sex,
problem & duration
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History of Present Illness (HPI)
Story of patients chief complaint (CC)
Story of any active/significant illnesses patient as
which impact on HPI
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History of Present Illness (HPI)
Story of CC (How To Ask):
start with open-ended questions
fill in with focused questions
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History of Present Illness (HPI)
Story of CC
Describe symptoms in terms of: location
quality
quantity (severity)
timing
setting
aggravating and/or alleviating factors associated manifestations
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History of Present Illness (HPI)
Story of CC
document:
prior medical Dx/Rx
significant positives or negatives
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History of Present Illness (HPI)
Story of CC
logical, complete, chronological
open-to-closed questioning
characterize symptoms document:
prior medical diagnoses/treatments
significant positives/negatives
patient's understanding of illnessStory of any active/significant illnesses patient has
which impact on HPI
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Past Medical History (PMH)
Childhood illnesses
Immunizations
Adult illnesses
Psychiatric illnesses or Hospitalizations
OperationsInjuries/accidents
Obstetric history
Transfusions
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Obstetric History
Number times pregnant
Number live births
Number abortions (spontaneous/induced)
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Transfusions
Where
When
Why
Reactions/complications
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Psycho-Social History (PSH)
Marital status
Living conditions
Employment
Sexual history
Significant life events
Mental status
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General Survey--Note:
Level of Consciousness
Apparent State of Health---Generalappearance--Age Appropriate?
State of Nutrition--Wasting?,..
Body Habitus
Maintain a watchful eye during
the medical interview
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Watchful eye and Ear-----
Speech
Facial Expressionsfear?/ stoic?
Appropriate facial responses tocommunication?
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BLOOD PRESSURE
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Whats The Difference???-better yet
What does it all mean?
Systolic BP = The Peak Pressure in the
arteries, regulated by Stroke Volume (SV)
and compliance of the blood vessels
Diastolic BP = lowest pressure in the
arteries, dependent on peripheral vascularresistance
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The Difference.Systolic-Diastolic
** Pulse Pressure**
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Which Cuff?..Appropriate size.
What if I get a different reading in one arm vs
other?
Right arm BP--5-10mm^ than left
Systolic BP in legs 15-20mm^ than in arms
PoiseuillesLaw: relates to the fact that the total
resistance of vessels conncected in parallel is greaterthan the resistance of a single large vessel.
Techniques of Exam--BP
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Techniques of Exam-BP
How to Assess?
Normal Values & Changes from the
Norm?Adult, Infant, Pregnancy, Geriatric...
Clinical Significance?Elevation-Hypertensive,
Low-HypotensiveOrthostatic Changes
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Pulse= denotes the heart rate & rhythm,
condition of the arterial walls
How to Assess?
What do my readings tell me? Rapid?
Slow?
Techniques of Exam--Pulse
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Complete Hx w/ ROS S.O.A.P Formats
Problem Specific
Maintaining Organization Remembering It All---Note as you go along---
Less lost Data
Hospital Records, Specified Forms (Clinics,Hospitals, HMOs)
EHR (Electronic health record)
How do I write it all down?
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