Review of System
- Order of assessment (head – to – toe)
- Part of health history - Limited to statements or subjective data
General Overall Health State – weight (gain or loss, period of time, by diet or other factors), fatigue,
weakness or malaise, fever, chills, sweats, or night sweats.
Skin – history of skin disease (eczema, psoriasis), change in pigmentation, texture or color, change in
mole, excessive dryness, sweating, pruritus, hair growth and distribution, excessive bruising, amount of
sun exposure, self-care
Hair – recent loss, change in texture, method of self care
Head - any unusually frequent or severe headache, any head injury, dizziness, syncope
Eyes – Difficulty with vision (decreased activity, blurring, blind spot), eye pain, diplopia, redness or
swelling, watering or discharge, glaucoma, photophobia, itching
Health promotion: wears glasses or contacts, last vision check or glaucoma test; how is she cping
with loss of vision if any
Ears – Earaches, infections, discharges and its characteristics, tinnitus or vertigo (sensation of spinning of
the room or self)
Health promotion: hearing loss, hearing aid use, how loss affects daily life, any exposure to
environmental noise, methods of cleaning ears
Nose and Sinuses – discharge and its characteristics, any unusually frequent or severe colds, sinus pain,
nasal obstruction, nosebleeds, allergies or hay fever or change in the sense of smell
Mouth and Throat – mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth and
tongue, dysphagia, hoarseness or vocal change, tonsillectomy, altered taste
Health Promotion – Pattern of daily dental care, use of prosthesis and last dental checkup
Neck – Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter
Breast – pain, lump, nipple discharge, rash, history of breast disease, any surgery on the breast
Health Promotion: performs breast self-examination (BSE), including its frequency and method
used, last mammogram
Pulmonary: Cough (duration, association with sputum production), change in chronic cough, trouble
breathing (dyspnea), wheezing, coughing up blood (hemoptysis), pain with taking a deep breath
(pleuritic chest pain), blue discoloration of lips or nailbeds (cyanosis), history of exposure to TB, history
of a previous TB skin test and the results if done, recurrent pneumonia, history of environmental
exposure
Cardiovascular: Chest pain (including details), dyspnea, paroxysmal nocturnal dyspnea (abbreviated
"PND"; patient will describe shortness of breath that improves when he or she sits up and dangles feet
off the bed), orthopnea (patient has to sleep on pillows to prevent shortness of breath; quantitate by
the number of pillows that the patient sleeps on), edema, palpitations, hypertension, known heart
disease, history of a murmur, history of rheumatic fever, syncope or near syncope, pain in posterior
calves with walking (claudication), varicosities, thrombophlebitis, history of an abnormal
electrocardiogram
Gastrointestinal: Trouble swallowing (dysphagia), pain with swallowing (odynophagia), nausea,
vomiting, vomiting blood (hematemesis), food intolerance, indigestion, heartburn, change in appetite,
sensation of filling up earlier than usual (early satiety),frequency and character (formed vs. loose) of
bowel movements, changes in bowel pattern, rectal bleeding, passing black tarry stools (melena),
constipation, diarrhea, abdominal pain, excessive belching or passing of gas, hemorrhoids, jaundice, liver
or gallbladder problems, history of hepatitis
Urinary: Blood in urine (hematuria), pain on uurination (dysuria), frequency, suprapubic pain,
costovertebral angle (CVA) tenderness, frequent urination at night (nocturia), passing large volumes of
urine on a frequent basis (polyuria), stones, inguinal pain, trouble initiating urinary stream,
incontinence, history of urinary tract infections
Genital tract (male): Penile discharge, lesions, history of sexually transmitted disease (STD), testicular
pain, testicular swelling, scrotal mass, infertility, impotence, change in libido, sexual difficulties, hernias
Genital tract (female): Age of menarche, last menstrual period, cycle (number of days; how much
bleeding, intermenstrual bleeding, postcoital bleeding, pain with intercourse (dyspareunia), vaginal
discharge, pruritus, contraceptive use, history of STD's, last Pap smear and results, age at menopause,
postmenopausal bleeding, infertility, change in libido, sexual difficulty, pregnancies (including live births
and abortions - both spontaneous and induced, complications of pregnancy particularly if these are
diabetes or hypertension
Musculoskeletal: Joint pains or stiffness, arthritis, gout, backache, joint swelling or tenderness or
effusion, limitation of motion, history of fractures
Neurologic: Fainting, blackouts, seizures, paralysis, local weakness, numbness, tingling, tremors,
memory changes, headaches, vertigo or dizziness, muscle atrophy
urination (dysuria), frequency, suprapubic pain, costovertebral angle (CVA) tenderness, frequent
urination at night (nocturia), passing large volumes of urine on a frequent basis (polyuria), stones,
inguinal pain, trouble initiating urinary stream, incontinence, history of urinary tract infections
Genital tract (male): Penile discharge, lesions, history of sexually transmitted disease (STD), testicular
pain, testicular swelling, scrotal mass, infertility, impotence, change in libido, sexual difficulties, hernias
Genital tract (female): Age of menarche, last menstrual period, cycle (number of days; how much
bleeding, intermenstrual bleeding, postcoital bleeding, pain with intercourse (dyspareunia), vaginal
discharge, pruritus, contraceptive use, history of STD's, last Pap smear and results, age at menopause,
postmenopausal bleeding, infertility, change in libido, sexual difficulty, pregnancies (including live births
and abortions - both spontaneous and induced, complications of pregnancy particularly if these are
diabetes or hypertension
Musculoskeletal: Joint pains or stiffness, arthritis, gout, backache, joint swelling or tenderness or
effusion, limitation of motion, history of fractures
Neurologic: Fainting, blackouts, seizures, paralysis, local weakness, numbness, tingling, tremors,
memory changes, headaches, vertigo or dizziness, muscle atrophy
Developmental Care
A. Additional information for health history for pediatric patients
- Reason for Seeking care/Chief Complaint
o Record parent’s spontaneous statement
o Explore hidden agenda
- Present health or history
o Include statement about usual health and any common health problems or major
health concerns.
Eg. The health status is generally good as stated by the mother. The child
had “one asthmatic attack” for the past 3 months
o Describe presenting s/sx (same as adult +)
Severity of pain
How did you know the child is in pain? (eg. Pulling of ears)
Effects of pain on Usual behavior
Reduces feeding? Stops him from playing? Refuses to go to school?
Parents coping ability and reaction of other family members to
child’s symptoms or illness
- Past health
o Prenatal Status
How was the pregnancy spaced
Was it planned
What was the mothers attitude to this pregnancy?
What was the father’s attitude to this pregnancy
Was there medical supervision for the mother?
At what month was the supervision started
Were there any complications (bleeding, excessive nausea and vomiting,
infections – German Measles)
What diet and medications were prescribed and/or taken during
pregnancy?
Did the mother smoke, take alcohol, use street drugs during pregnancy?
Did the mother undergo any xray studies during pregnancy?
Start with open-ended question: “Tell me more about your pregnancy?”
o Labor and Delivery
Parity of mother
Duration of pregnancy (term?)
Place of delivery
Type of delivery
Birth weight, length, HC, CC, need for resuscitation, MV or procedure
o Post natal status
Any problems in nursery?
Length of hospital stay
Neonatal jaundice
Breastfed or bottlefed?
Patterns or crying and sleeping
Mother’s health post partum
Mother’s reaction to baby
- Developmental History
o Growth
Height and weight at birth, at 1, 2, 5, 10
Process of dentition
o Milestones
Motor development
Language
Toilet training
Do parents believe this development has been normal?
How does this child’s development compare to siblings or peers?
o Current Development
Gross motor skills (rolls over, sit alone, skips, climbs)
Fine motor skills (brings hand to mouth, pincer grasp, stacks blocks, feeds
self, uses crayons to draw, uses scissors)
Language skills (first word with meaning, vocabulary, sentences, persistence
of baby talk)
Personal – Social skills (smiles, follow movements with eyes, turns head
towards sounds, recognizes own name)
Toilet – training (method used, age, parent’s attitude, terms used for
toileting)
o Nutritional History
Breast feeding or bottle – frequency, amount, duration, supplements
Any problems with bottle-feeding (spitting, colicdiarrhea)
Introduction of solid food – what foods are given, reaction to new food
For preschool, school aged and adolescents
Appetite to eat
24-hr diet recalls
Vitamins
How much junk food eaten
Food likes and dislikes
Parent’s perception of child’s nutrition
B. Additional Information for Health History in Pregnancy
o Age
Adolescent (younger than 19yrs old) have higher incidence of anemia, PIH,
PTL, SGA,IUGR, CPD, and dystocia
Advanced age (over 35 yrs old) have increased incidence of HTN, diabetes,
medical gestation, infants with genetic abnormalities
o Family History
Maternal and paternal history
Congenital disorders
o Woman’s Medical History
Childhood diseases (rubella)
Major illness, surgery of reproductive tract
Drug, food , environmental allergens
UTI, HTN, DM, anemias, endocrine problems
Use f contraceptives
Hx of STI
Menstrual history
Menarche, duration, amount, regularity and pain(dysmenorrhea,
metorrhagia(bleeding between perios)
o Woman’s Past Obstetric history
Problems of infertility, dates of previous pregnancies and deliveries: infant’s
weight, length of labor; types of deliveries, multiple birth, abortion,
maternal, fetal and neonatal complications
Woman’s perception of past pregnancy, labor and delivery for herself and
effect on her family
o Woman’s Present Obstetric history
Gravity, parity
Gravida (G) – woman who is or has been pregnant, regardless of
pregnancy outcome; regardless of fetuses
Para (P) – refers to the past pregnancies that have reached viability
Nulligravida – woman who is not now and never has been pregnant
Primigravida – woman pregnant more than once
Nullipara – woman who has never completed a pregnancy to the
period of viability (capability of living, 24 weeks)
Primipara – woman who has completed one pregnancy to the
period of viability regardless of the number of infants delivered and
regardless of the infant being live or stillborn
Multipara – woman who as complete two or more pregnancies to
the stage of viability
o Examples G1P0 – woman who is pregnant for the first time
G2P1 – woman who is pregnant for the second
time and has delivered one fetus carried to the period of
viability
Obstetric history GTPALM
G – ravida
T – term deliveries > 37 weeks
P – preterm deliveries 20 – 36 weeks
A – abortion – elective or spontaneous loss of pregnancy before the
period of viability (less than 20 weeks)
L – living children a woman has delivered regardless of whether
they were living births or stillborn births
M – multiple gestations and births (not number of neonates
delivered
o Eg. G5, P5 – T0P0A0L6M1 the woman has been pregnant 5
times, has 5 term deliveries, 0 preterm, 0 abortion, 6 living
children, 1 multiple gestation/birth
Date of LMP – first day of last menstrual period
Estimated date of confinement/delivery
Nagele’s rule:EDD
o Subtract 3 months
o Add 7 days to the 1st day of LMP
o Add 1 year
Ex. LMP = April 9, 1978
4 9 1978
-3 +7 +1
1 16 1979 = EDD
S and Sx of pregnancy: amenorrhea, breast changes, nausea and vomiting,
urinary frequency, skin pigmentation, enlargement of abdomen, fetal
movement
Sexual Activity – sexual satisfaction, frequency and positions
Diet hx
Psychosocial status – emotional changes she is experiencing, women’s and
family’s reactions to present pregnancy, support system
