HEALTH HISTORY- conversation with a “My stomach hurts and I feel awful”

purpose.
“I have come for my regular check-up”
COMPONENTS OF THE HEALTH HISTORY
• PRESENT ILLNESS
1. Identifying Data
- Complete, clear and Chronologic account
2. Reliability
of the problems prompting the patient to seek
3. Chief Complaint (s)
care.
4. Present Illness
5. Past History - It should include the problem’s onset, the
6. Family History setting in which it has developed, its - together with results and the dates they
7. Review of System manifestations, and any treatments. were last performed
• DEMOGRAPHIC DATA 7 ATTRIBUTES OF EVERY SYMPTOMS • FAMILY HISTORY
- Date and Time of History 1. Location - Grandparents
- Name 2. Quality - Parents
- Age 3. Quantity/ Severity - Siblings
- Gender 4. Timing - Children
- Marital Status 5. Setting - Grandchildren
- Occupation 6. Aggravating and Relieving Factors
7. Associated Manifestations - Legends:
• IDENTIFYING DATA
• PRESENT ILLNESS ■ male
- Subjective Data
- Medications, including name, dose, route, ● female
- What the patient tells you.
and frequency of use.
★ patient
- The symptoms and history, from
- Allergies, including specific reactions to
chief complaint through review of system.
each medication. ▲ pets
- Objective Data ✕ deceased
- Tobacco use; and alcohol and drug use.
- What you detect during the
• PAST HISTORY INTERVIEWING SKILLS
examination, laboratory information, and test
data. • GOAL- to listen and improve the well-being of
- All physical examination findings, or the patient through a trusting and supportive
signs relationship
• CHIEF COMPLAINT
- Quote the patient’s own words.
 - HEALTH HISTORY- a structured framework for 9. Stethoscope
organizing patient information into written or
THE SEQUENCE OF THE INTERVIEW
verbal form
1. Greet the px and establish rapport
- INTERVIEWING PROCESS- it is “open-ended”,
2. Establish an agenda
drawing on a range of techniques the affirm and
3. Invite the px’s story
empower the patient.
4. Explore the px’s perspective
THE FUNDAMENTALS OF SKILLED 5. Identify and respond to the px’s
INTERVIEWING emotional cues
6. Expand and clarify the px’s story
- Active listening
7. Generate and test diagnostic
- Emphatic Response
hypotheses 10. Otoscope
- Guided Questioning
8. Share the treatment plan 11. Ophthalmoscope
- Nonverbal communication- eye-to-eye,
9. Close the interview and visit 12. Visual Acuity Chart
facial reaction, hand gestures
10. Take time for self- reflection 13. Nasal Speculum
- Validation- valid information coming
14. Tuning Fork
from the px TOOLS for HEALTH ASSESSMENT
15. Reflex Hammer
- Reassurance- privacy and confidentiality
1. Pen and paper 16. Senses
- Summarization- babalikan lahat ng
2. Tape measure
pinag- usapan
3. Clean gloves
- Transition- from your topic; patient’s
4. Pen light
topic to gradual transition to your topic
5. Weighing Scale
- Empowering the patient
6. Thermometer
The SEQUENCE and CONTEXT of the INTERVIEW 7. Tongue Depressor
8. Sphygmomanometer
PREPARATION, SEQUENCE, and CULTURAL
CONTEXT

1. Review the clinical record

2. Set goals for the interview
3. Review your clinical behavior and
appearance
4. Adjust the environment - Tuning Fork and Reflex Hammer
INTEGUMENTARY SYSTEM • HEALTH HISTORY
- Common or concerning symptoms:
Growths
Rash
Hair Loss
- GROWTHS
“Have you noticed any changes in your
skin? … your hair? … your nails?
“Have you had any rashes? … sores? …
lumps?
Personal and Family History of skin cancer
TYPE, LOCATION, DATE of OCCURENCE
Regular self-skin examination and use of
sunscreen
- RASHES
Ask about itching
Does itching precede with rash or follow the
rash
For itchy rashes, ask about seasonal
allergies with itching and water eyes, asthma,
and atopic dermatitis
Can the patient sleep all night or does itching
wake up the patient?
FUNCTIONS
- HAIR LOSS or NAIL CHANGES
1. Protection
2. Sensory Is there hair thinning or hair shedding? TECHNIQUES for the EXAMINATION
3. Water Balance
4. Temperature Regulation Onychomycosis PREPARING for the EXAMINATION
5. Involved in the activation of Vitamin D Habit tic deformity - Good ambient lighting or natural light
6. Involved in Wheal and Flare reaction - Small ruler or tape measure
Melanonychia
- Small magnifying glass
 - Ask the patient to change into a gown - Texture - Diaphoresis- excessive, abnormal
with the opening in the back and clothes - Elasticity sweating.
removed except for underwear - Turgor - Edema- is the presence of excess
interstitial fluid
EXAMINATION NORMAL FINDING
- Anasarca- whole body swells up
- Examination of the skin is correlated with - “normal” - Poor skin turgor
the information gathered in the history - Capillary refill - Skin Lesions with Blue- Green
and other parts of the physical - Warm, moist, smooth and good skin Fluorescence
examination. turgor - Dull, coarse or brittle scalp hair
- Examine the skin as you proceed - Characteristic Hair Distribution - Hirsutism- unwanted, male-pattern hair
through each body system - Nails are present and smooth growth in women
- Initially, examine both hands and inspect - Koilonychia- Changes in the color,
ABNORMAL FINDINGS shape, or texture of finger or toenails
the nails
- Vitiligo- patches of hypopigmented skin, - Onycholysis- separation of a fingernail
INSPECTION or toenail from its pink nail bed
is caused by the destruction of
- Skin color melanocytes in the area PARTS and FUNCTIONS OF THE EYES
- Pigmentation - Pigmented Lesions
- Lesions (Distribution, type, configu- - Seborrhea- It causes a red, itchy rash
ration, size) and white scales. When it affects the
- Jaundice- (a yellowish tinge) may first scalp, it is called “dandruff.”
be evident in the sclera of the eyes and - Xerosis- dry skin
then in the mucous membranes and the - Pruritus
skin - Alopecia- hair loss
- Cyanosis- (a bluish tinge) is most - Pallor- is the result of inadequate
evident in the nail beds, lips, and buccal circulating blood or hemoglobin and
mucosa subsequent reduction in tissue
- Scars oxygenation.
- Superficial vascularity - Erythema- is skin redness associated
- Moisture with a variety of rashes and other
- Edema-is the presence of excess conditions.
interstitial fluid - Cyanosis- (a bluish tinge) is most
- Color mucous membranes evident in the nail beds, lips, and buccal
- Hair distribution mucosa
- Nails - Jaundice- (a yellowish tinge) may first
be evident in the sclera of the eyes and
PALPATION
then in the mucous membranes and the
- Temperature skin
PARTS and FUNCTIONS OF THE EYE NORMAL RESULT: 20/20 - Entropion- eyelids turns inward
-Iris Numerator: Indicates distance of the patient - Exophthalmos
-Cornea from the chart
- Enophthalmos
- Lens- it refracts and focuses light rays
Denominator: Indicates the distance at which
- Sclera- supports and protects eyeball - Conjunctivitis- inflammation of the bulbar and
the normal eye can read the letter
- Retina- *retinal detachment- glaucoma; palpebral conjunctiva
sensory receptors- rods (B&W), cones ABNORMAL FINDINGS
(colored) PARTS and FUNCTION of the EARS
- Optic nerve- transmit impulse to the brain • Visual Acuity
- Pinna- collects sound waves;
- Anterior Chamber aqueous humor- fluid - If the denominator is increased (20/30 protection; help determine when the
produced by the eye. or greater), the patient has myopia sound came from
SYSTEM ASSESSMENT (EYE) - If the denominator is decreased (20/15 Carrier of sound waves- solid, liquid,
or greater), the patient has hyperopia gas
INSPECTION and FINDINGS - If the result is 20/200, the patient is - Auditory Canal- entry way of sound:
legally blind. provide ear wax (lubricant, protection)
- Eyeballs
- Eardrum- sends vibration to the inner
PALPATION and FINDINGS
- Palpebral fissures- longitudinal distance ear: barrier
- Determine the strength of the upper - Malleus (Hammer)- transport from
- Lid Margins- pinkish/ reddish color; yung
eyelids by attempting to open closed lids eardrum to incus
malapad sa loob
against resistance - Incus (anvil)
- Bulbar and Palpebral Conjunctivae - Palpate eyeballs through closed lids for - Stapes (stirrup)
tenderness and tension - Cochlea- interpret and convert
- Lateral canthus soundwave
ABNORMAL FINDINGS - Auditory nerves
- Sclera
- Myopia- nearsightedness - Tragus- protector
- Pupils
- Hyperopia- farsightedness INSPECTION and FINDINGS
- Eye movement- 6 cardinal position (III, IV, VI
cranial nerves) - Presbyopia- loss of elasticity of the lens and
thus loss of ability to see close objects
- Nystagmus- uncontrolled and rapid
eye movement - Nystagmus- condition of involuntary eye
movement.
- Convergence eye movement- to
focus to a very close object. - Lid Lag
NORMAL FINDINGS - Ptosis of the eyelid
• Visual Acuity - Ectropion
• PINNA- external auditory canal PALPATION AND FINDINGS conduction (AC) is better than bone
conduction (BC)
- Size- 2.5 inches: may indicate disease • PINNA
TUNING FORK TESTS- WEBER TEST
- Shape- disease or trauma - Tenderness
- Test for lateralization of vibration.
- Color - Consistency of the cartilage
Place the rounded tip of the handle of the
- Lesions- sugar - Swelling vibrating tuning fork in the middle of the
scalp, near the forehead.
- Masses- bukol; abnormal cell growth - Move pinna and push tragus for tenderness - Normally, sound is heard in the center of
- Symmetry MECHANICAL TESTS FOR HEARING the head or equally in both ears.
- A patient with normal hearing can hear
• EXTERNAL CANAL WHISPER VOICE TESTS a whispered word from approximately
4.5 meters (15 feet) and a watch from
- Discharge - Go to the side of the patient, 15 feet away
30cm (12 inches)
from the ear being tested.
- Impacted cerumen - The patient should hear the sound
- Cover the ear not being tested
equally well in both ears, that is, there
- Inflammation - Whisper 2-syllable words
is no lateralization
- A patient with normal hearing can hear
- Masses a whispered word from approximately ABNORMAL FINDINGS
- Foreign Bodies 4.5 meters (15 feet) and a watch from
30cm (12 inches) - Otalgia- pain in the ear
• TYMPANIC MEMBRANE - The patient should hear the sound - Otorrhea- ear discharge
equally well in both ears that is, there
- Color- pale gray - Presbycusis- age-related hearing loss
is no lateralization
- Luster- ability to vibrate - Tinnitus- noise or ringing in the ears
TUNING FORK TESTS- RINNE TEST
- Shape- parang pinipi na cone - Vertigo- sensation of feeling off balance
- Compares air and bone conduction.
- Position - Place vibrating tuning fork on the
- Microtia- small ears; less than 2.5
mastoid process behind the ear and
- Transparency- translucent have the patient tell you when the - Macrotia- large ear; more than 4.5
- Integrity vibrating stops.
- Impacted Cerumen- bacterial infection
- Then quickly hold the vibrating end of the
- Scarring tuning fork near the opening of the ear - Otitis media- inflammatory diseases of the
canal (2 inches away) and ask if the middle ear
TO EXAMINE WITH OTOSCOPE
patient can hear it.
- Normally, sound should be heard after - Otitis externa- inflammation of the ear canal.
vibration can no longer be felt, that is, air