Slide 1 H & P for Dental Student

7/29/2019 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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This information

should be presented

in a logical fashion

that prominentlyfeatures all data

immediately relevant

to the patient's

condition.


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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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General Examination


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General


nose, throat.


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General




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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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General



Neck


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General



Neck

Breasts and axillae


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General



Neck

Breasts and axillae

Thorax and lungs


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General



Neck

Breasts and axillae

Thorax and lungs

CVS & peripheralvascular system


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General



Neck

Breasts and axillae

Thorax and lungs


Abdomen


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General



Neck

Breasts and axillae

Thorax and lungs


AbdomenGenitalia


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General



Neck

Breasts and axillae

Thorax and lungs


AbdomenGenitalia

Musculoskeletal

system


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General



Neck

Breasts and axillae

Thorax and lungs


AbdomenGenitalia

Musculoskeletal

systemNeurologic exam


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Questions

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Slide 1 H & P for Dental Student

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