slide 1 h & p for dental student
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Introduction, History &
Physical Examination
Khaled Obeidat MD
Department of Surgery
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The written History and Physical (H&P)
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History
Pts Profile
Chief Complaint (CC)
History of PresentIllness (HPI)
Review of Systems
Past History
PMH, PSH
Meds, Allergies
Social History (SH)
Family History (FH)
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H & P serves several purposes
It is an important
reference document a
patient's history and
exam findings at thetime of admission.
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H & P serves several purposes
This information
should be presented
in a logical fashion
that prominentlyfeatures all data
immediately relevant
to the patient's
condition.
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H & P serves several purposes
It allows students
demonstrate theirability
to accumulate historical
and examination based
information, make use oftheir medical knowledge,
and derive a logical plan
of attack.
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H & P
Knowing what to
include and what to
leave out will be
largely dependent onexperience and your
understanding of
illness and
pathophysiology.
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H & P
If you were unaware
that chest pain is
commonly associated
with coronary arterydisease, you would
be unlikely to mention
other coronary risk-
factors when writingthe history.
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H & P
Until you gain
experience, your
write-ups will be
somewhat poorlyfocused. Not to worry;
this will change with
time and exposure.
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Patients Profile
Name
Age or DOB
GenderOccupation
Marital status
AddressSource of information
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Chief Complaint or Chief
Concern (CC)
One sentence that
covers the dominant
reason(s) for
hospitalization or visit
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HISTORY OF PRESENT ILLNESS
THIS IS THE
DESCRIPTION OF
THE PATIENTS
ILLNESS AS TOLDBY THE PATIENT,
OR FAMILY, OR A
COMBINATION OF
THE TWO.
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History of Present Illness
Physician asks
questions to analyze thedetails of the chief
complaint.
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History of Present Illness answers
questions of ..
When the problem
began, what and
where the
symptoms are,what makes the
symptoms worse
orbetter.
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History of Present Illness
Very brief
pain after hitting
their finger with ahammer
More detailed.
abdominal pain
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Chronological description of the
development of the patient's present
illness from the first sign and/orsymptom
0
Abdominal pain
10
Fever and chills
15
jaundice
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History of Present Illness (PAIN)
Location
Quality
Severity
DurationTiming
Context
Modifying factors
Associated signs andsymptoms.
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Review of systems
Questions about common symptoms in
each major body system which may help
to identify problems that the patient has
not mentioned
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Review of Systems (ROS)
The most important ROS questioning (i.e.
pertinent positives and negatives related
to the chief complaint) is generally noted
at the end of the HPI.
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REVIEW OF SYMPTOMS
PURPOSEA WAY TO MAKE SURE YOU
DID NOT MISS A PROBLEM
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REVIEW OF SYMPTOMS
HEAD
EYES
EARS
NOSE
THROAT
RESPIRATORY
CARDIOVASCULAR
GASTROINTESTINAL
UROGENITAL
OBSTETRIC ANDGYNECOLOGIC
MUSCULOSKELETAL
NEUROLOGICAL
ENDOCRINE
SKIN
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Review of Systems (ROS)
It is probably a good idea to practiceasking all of these questions as well asnoting the responses so that you will be
better able to use them for obtaininghistorical information when interviewingfuture patients
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Past Medical History (PMH)
This should include
any illness (past or
present) for which the
patient has receivedtreatment.
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Past Surgical History (PSH)
All past surgeries
should be listed,
along with the rough
date when theyoccurred.
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Medications (MEDS)
Includes all currently
prescribed
medications as well
as over the counterand non-traditional
therapies. Dosage
and frequency should
be noted.
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Allergies/Reactions
Identify the
specific reactionthat occurred
with each
medication.
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Social History (SH)
Alcohol Intake
Smoking
Other Drug Use
Marital Status
Sexual History
Work History
Income
Housing and Address
Other . travel
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Work/Hobbies/Other
What sort of work doesthe patient do?
Have they always donethe same thing?
Do they enjoy it?If retired, what do they doto stay busy?
Any hobbies?
Participation in sports orother physical activity?
Where are they fromoriginally?
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Work/Hobbies/Other
It is nice to know
something non-medical.
This help improve the
patient-physician bond.
It also gives you
something to refer back
to during later visits,
letting the patient know
that you paid attentionand really remember
them.
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Family History (CIRCLE ANY CONDITION WHICH YOU
OR ANY BLOOD RELATIVE HAVE HAD)
Diabetes
High Blood
Pressure
IHD
Cancer
Arthritis
TBStroke
Epilepsy
Psychiatric Disorder
Anesthesia
Problems
Osteoporosis
Other
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
Neck
Breasts and axillae
Thorax and lungs
CVS andperipheral vascular
systemAbdomen
Genitalia
Musculoskeletalsystem
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Physical examination
General Examination
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, throat.
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
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Physical Exam
Neurologic:
1,Mental Status
2,Cranial Nerves3,Motor Strength
4,Function,
Observed Ambulation
Neurologic:
5,Sensation (light
touch, pin prick,
vibration and position)6,Reflexes, Babinski
Cerebellar
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
Neck
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
Neck
Breasts and axillae
-
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
Neck
Breasts and axillae
Thorax and lungs
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
Neck
Breasts and axillae
Thorax and lungs
CVS & peripheralvascular system
-
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
Neck
Breasts and axillae
Thorax and lungs
CVS & peripheralvascular system
Abdomen
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
Neck
Breasts and axillae
Thorax and lungs
CVS & peripheralvascular system
AbdomenGenitalia
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
Neck
Breasts and axillae
Thorax and lungs
CVS & peripheralvascular system
AbdomenGenitalia
Musculoskeletal
system
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Physical examination
General
HEENT: Includeshead, eyes, ears,
nose, & throat.Oral cavity
Neck
Breasts and axillae
Thorax and lungs
CVS & peripheralvascular system
AbdomenGenitalia
Musculoskeletal
systemNeurologic exam
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Questions
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