Putting the History and Physical Examination Together

Until this point, this book has dealt separately with the history and the physical examination. Chapters 1 to 6 give an in-depth analysis of history-taking techniques. Chapters 7 to 21 discuss the many elements of the physical examination, and Chapter 22 suggests an approach to performing the complete physical examination and its write-up. Chapters 23 to 26 cover the evaluation of specific patients. Chapter 27 discusses data gathering and data analysis. This chapter suggests how the history and the physical examination can be integrated into one succinct statement about the patient.

In writing up the history and the physical examination, the examiner should follow several rules:

# Record all pertinent data

# Avoid extraneous data

Use common terms

Avoid nonstandard abbreviations

# Be objective

Use diagrams when indicated

The patient's medical record is a legal document. Comments regarding the patient's behavior and attitudes should not be part of the record unless they are important from a medical or scientific standpoint. Describe all parts of the examination that you performed and indicate those that you did not perform. A statement such as ''the examination of the eye is normal'' is much less accurate than ''the fundus is normal.'' In the first case, it is not clear whether the examiner actually attempted to look at the fundus. If a part of the examination was not performed, state that it was ''deferred'' for whatever reason. Finally, it is not necessary to state all the possible abnormalities if they are not present. It is acceptable to state that ''the pharynx was normal'' instead of ''the pharynx was not injected, and there was no evidence of discharge, erosion, masses, or other lesions.'' It is clear from the first statement that the examiner inspected the pharynx and believed that it was normal.

Now consider again the patient Mr. John Doe, whose interview was recorded in Chapter 6, Putting the History Together. The following text describes the complete history and physical examination of this patient.

Patient: John Doe Date: July 19, 2009

History Source

Self, reliable. Chief Complaint

''Chest pain for the past 6 months.'' History of Present Illness

This is the first St. Catherine's Hospital admission for this 42-year-old lawyer with atherosclerotic coronary artery disease. The patient's history of chest pain began 4 years before admission. He described the pain as a ''dull ache'' in the retrosternal area, with radiation to his left arm. The pain was provoked by exertion and emotions. On July 15, 2008, Mr. Doe suffered his first heart attack while playing tennis. He had an uneventful hospitalization in Kings Hospital in New York City. After 3 weeks in the hospital and 3 weeks at home, he returned to work. The patient suffered a second heart attack 6 months later (January 9, 2009), again while playing tennis. The patient was hospitalized in Kings Hospital, during which time he was told of an ''irregularity'' in his heart rate. Since then, the patient has not experienced any palpitations, nor has he been told of any further irregularities.

Over the past 6 months, Mr. Doe has noted an increase in the frequency of his chest pain. The pain now occurs four to five times a day and is relieved within 5 minutes with one or two nitroglycerin tablets under his tongue. The pain is produced by exercise, emotions, and sexual intercourse. The patient also describes one-block dyspnea on exertion. The patient relates that 6 months ago, he could walk two or three blocks before becoming short of breath.

Although the patient shows significant denial of his illness, he is anxious and depressed. The patient has currently been admitted for elective cardiac catheterization.

Past Medical History

General: Good.

Past illnesses: History of untreated hypertension for years (blood pressure not known);no history of measles, chickenpox, mumps, diphtheria, or whooping cough.

Injuries: None.

Hospitalizations: Appendectomy, age 15 years, Booth Memorial Hospital in Rochester, New York (Dr. Meyers, surgeon).

Surgery: See Hospitalizations.

Allergies: None.

Immunizations: Salk vaccine for polio, tetanus vaccine, both as a child; no adverse reactions remembered.

Substance abuse: A 40-pack-year (2 packs a day for 20 years) history of smoking; stopped smoking after first heart attack;marijuana on rare occasions in past;drinks alcohol ''socially'' but also admits to feeling the need for a drink as the day goes on (CAGE score, 1);denies use of other street drugs.

Diet: Mostly red meat, with little fish in diet; three cups of coffee a day; recent decrease in appetite, with a 10-pound weight loss in past 3 months.

Sleep patterns: Recently, falls asleep normally but awakens around 3 AM and cannot go back to sleep.

Current medications:

Atenolol, 50 mg once daily Isosorbide dinitrate, 10 mg qid Nitroglycerin, 1/150 grains prn

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