Health History and Examination Health Assessment of the Head

1 The techniques of physical examination and history taking that you are about to learn embody time-honored skills of healing and patient care. Your ability to gather a sensitive and nuanced history and to perform a thorough and accurate examination deepens your patient relationships, focuses your patient assessment, and sets the direction of your clinical thinking. The quality of your history and physical examination governs your next steps with the patient and guides your choices from the initially bewildering array of secondary testing and technology. Over the course of becoming an accomplished clinician, you will polish these important relational and clinical skills for a lifetime. As you enter the realm of patient assessment, you begin integrating the essential elements of clinical care: empathic listening; the ability to interview patients of all ages, moods, and backgrounds; the techniques for examining the different body systems; and, finally, the process of clinical reasoning. Your experience with history taking and physical examination will grow and expand, and the steps of clinical reasoning will soon begin with the first moments of the patient encounter: identifying problem symptoms and abnormal findings ; linking findings to an underlying process of pathophysiology or psycho-pathology; and establishing and testing a set of explanatory hypotheses. Working through these steps will reveal the multifaceted profile of the patient before you. Paradoxically, the very skills that allow you to assess all patients also shape the image of the unique human being entrusted to your care. Clinical Assessment: The Road Ahead This chapter provides a road map to clinical proficiency in three critical areas: the health history, the physical examination, and the written record, or " write-up. " It describes the components of the health history and how to organize the patient's story; it gives an approach and overview to the physical examination and suggests a sequence for ensuring patient comfort; and, finally, it provides an example of the written record, showing documentation of findings from a sample patient history and physical examination. By studying the subsequent chapters of the book and perfecting the skills of examination and history taking described, you will cross into the world of patient assessment— gradually at first, but then with growing satisfaction and expertise.

As you read about successful interviewing, you will first learn the elements of the Comprehensive Health History. For adults, the comprehensive history includes Identifying Data and Source of the History, Chief Complaint(s), Present Illness, Past History, Family History, Personal and Social History, and Review of Systems. As you talk with the patient, you must learn to elicit and organize all of these elements of the patient’s health. Bear in mind that during the interview this information will not spring forth in this order! However, you will quickly learn to identify where to fit in the different aspects of the patient’s story. As you gain experience assessing patients in different settings, you will find that new patients in the office or in the hospital merit a comprehensive health history; however, in many situations a more flexible focused, or problemoriented, interview may be appropriate. Like a tailor fitting a special garment, you will adapt the scope of the health history to a number of factors: the patient’s concerns and problems; your goals for assessment; the clinical setting (inpatient or outpatient; specialty or primary care); and the amount of time available. Knowing the content and relevance of all components of the comprehensive health history allows you to choose those elements that will be most helpful for addressing patient concerns in different contexts.