PHYSICAL DIAGNOSIS | HEALTH HISTORY: CLINICAL REASONING

SUBJECTIVE VS. OBJECTIVE

USLS College of Medicine ● Subjective information is equivalent to a

Topic: Health History: Clinical Reasoning ‘symptoms’ which are health concerns that the
Date: September 2, 2024 patient tells you.
● Objective information is the physical
Lecturer: Dr. Ricky Alayon examination findings or signs you detect during
the examination.
○ Laboratory and Diagnostic results
OUTLINE

● Content of Clinical History

○ Chief Complaint
○ History of Present Illness
○ Past Medical History
○ Family History
○ Personal and Social History
○ Review of Systems
● Modification in Clinical Interview
INITIAL INFORMATION
Key to a thorough and accurate physical examination
——> BE SYSTEMATIC ● Date and time of history
(Minimize the number of times you ask the patient to ● Identifying data
change of position) ○ Patient’s name in abbreviated initials
○ Age and gender
DIFFERENT KINDS OF HEALTH HISTORIES ○ *Where patient stays, religion, and
handedness
● Source of information
● Comprehensive Health History ● Reliability
○ For new patients
● Focused of Problem-Oriented History
○ For patients seeking care for a specific Additional notes: Reliability cannot be 100% because
several factors can affect the accuracy of the info gathered
concerns
● Focus on Patient’s Self-Management,
Response to Treatment, Functional Capacity,
CHIEF COMPLAINT
Quality of Life
○ For patients seeking care for ongoing or
chronic problems ● Gathering information
● Focus on Psychological or Psychiatric ○ This is the presenting complaint of
Conditions patient or the primary problem of patient
○ For patients recurrently seeking prompting clinic visit
schedules ● Documentation
○ When documenting chief complaint,
make every attempt to “quote” the
patient’s own words especially if it is
descriptive, unusual, or unique

Additional notes: CC will ALWAYS be subjective

Subjective Objective

Pain Tenderness

Redness Erythema

Swelling Edema

Transcriber: Mapa, D.J., Poblete, G.

Reference: Dr. Ricky Alayon’s PPT, Bates’ Guide to Physical Examination and History Taking, 15th Ed.
 PHYSICAL DIAGNOSIS | HEALTH HISTORY: CLINICAL REASONING

● How are you going to document?

HISTORY OF PRESENT ILLNESS
○ Start with an opening statement
(general data and chief complaint)
● The HPI on its most basic form is the story of ● Elaboration of chief complaint giving attention to
patient’s problem chronology (HPI)
● Always remember that the information flows ● Take note of accompanying symptoms and the
spontaneously and chronologically from what absent symptoms
patient tells you ● Include other pertinent information
● This is where you characterize the chief
complaint fully by describing its attributes
PAST MEDICAL HISTORY

● This includes all medical problems of the patient

whether active or remote
○ Adult illnesses (be specific, to include
maintenance medications)
○ Surgical history (type of surgery & date)
○ Childhood illnesses
○ Immunization

Additional notes: Past medical history includes recurrence of

diseases

FAMILY HISTORY

● Focuses on the health information of immediate

relatives
● Use family pedigree chart, especially in
hereditary illnesses

PERSONAL AND SOCIAL HISTORY

● This captures the patient personality and interest

● Focuses on occupation and education,
significant relationship, home environment
● Also includes sexual orientation and gender
identification and sexual history
● Lifestyle, vices, that is smoking history, alcoholic
beverages intake, and illicit drug use
Transcriber: Mapa, D.J., Poblete, G.
Reference: Dr. Ricky Alayon’s PPT, Bates’ Guide to Physical Examination and History Taking, 15th Ed.
 PHYSICAL DIAGNOSIS | HEALTH HISTORY: CLINICAL REASONING

the acuity of patient, its fast pace, and its

REVIEW OF SYSTEMS
round-the-clock nature
● Your information gathering may be interrupted
● These questions may uncover problems or especially in life threatening conditions or patient
symptoms that you or the patient may have needs to be taken samples for testing
overlooked, particularly in areas unrelated to ● In situation where patient is unconscious or
HPI change in mental status, obtain the health
● This is also called as the 'scanning' method history from family members, caregivers, etc.
● Think about asking a series of questions from
head to toe
● Remember that major symptoms discovered INTENSIVE CARE UNIT
during the Review of Symptoms which may be
related to patient's chief complaint should be ● The biggest obstacle you will face in gathering
moved to HPl in the write up health history in the ICU is that most patients
have limited abilities to communicate
Additional notes: ROS is subjective, and can help in ● Again, you will rely on obtaining health history
differential diagnosis from a family member or other clinicians

NURSING HOME
RECORDING YOUR FINDINGS

● Your goal is to produce a clear, concise, but ● Patients are often called as residents
comprehensive report Includes important ● You need to identify those residents with
pertinent information relating to the problem cognitive disability - you will be needing the
presented by the patient family or clinical staff in obtaining health history
● No false information, that is creating information
not obtained from the patient End of Transcription
● And again, BE SYSTEMATIC

MODIFICATION OF THE CLINICAL INTERVIEW

● As you proceed toward higher years, you will

encounter patients in a variety of clinical settings
ranging from ambulatory clinics to inpatient
wards to busy emergency rooms
● Hence, it is important to modify and tailor your
health history taking in various clinical care sites

AMBULATORY CARE CLINIC

● The clinic is probably one of the most ideal

clinical setting for conducting a history
● Patient may provide clinical information more
readily that hospitalized patients

EMERGENCY CARE

● Emergency department can be a daunting place

to take medical history, taking into consideration

Transcriber: Mapa, D.J., Poblete, G.

Reference: Dr. Ricky Alayon’s PPT, Bates’ Guide to Physical Examination and History Taking, 15th Ed.