During the first few days of your hospitalization and before your operation, your own doctor or a hospital doctor will take your complete medical history and perform a complete physical examination. This will be written in the space provided in your chart, for ready reference. If your own doctor is familiar with your medical history and if he has recently examined you, he may forego the procedure in the hospital, but in most cases you will be interviewed and examined during the first part of your hospitalization. Answer all questions precisely and completely, and be courteous. Your examination will be as complete as is necessary, so freely submit even if you have just been examined recently. It is advantageous to good medical care to have thorough and repeated examinations. Remember that your doctor has requested the hospital doctors to help in your care.
The first thing the interrogator will want to know is your chief complaint, the one symptom which bothers you most. This will be discussed in detail and all related symptoms will be reviewed in the study of the present illness. The interviewer will want to know the duration, severity, persistency, and all other details of each symptom. After the present illness has been completely elicited, a review of systems is made. You are asked specifically of any symptoms in all the systems of your body. By interrogation the interviewer will search for symptoms of the head, eyes, ears, nose, mouth, and throat; the cardiorespiratory (heart and breathing) system; the gastrointestinal (digestive) system; the genitourinary (genitals and urine excretion) system, and the extremities. All symptoms of any system of the body will be elicited to determine the effects of the present illness on other organs and to determine whether concurrent disease is present. The review of systems is a most important part of your interview, for it suggests your general state of health.
A study of your past history is made; this includes a survey of all previous illnesses, hospitalizations, operations, accidents, and births. A study of the family history is then made to determine the familial disease propensities you may have. Questioning of your personal and social habits may be necessary.
Physical examination is done to include all systems of the body. The examiner will inspect the eyes, ears, nose, mouth, throat, and neck; the chest will be examined to include study of the heart, lungs, and breasts; abdominal examination will search for any abnormality of the abdominal contents; the genitalia will be inspected, as will the extremities. The blood pressure is taken. In most cases a rectal examination will be done, and vaginal examination is often indicated. The acuity of each part of the examination depends in part on the symptoms elicited in the review of systems and the symptomatology of the present illness.
The physician uses several instruments in the course of his physical examination to aid his visual and palpatory senses. A lighted scope and tongue blade are used in examining the systems of the head; a stethoscope aids heart, lung, and abdominal examinations; percussion hammers help test the function of nerve reflexes, and various other special devices are employed frequently.
The importance of the history and the physical examination cannot be overemphasized. This is the starting point of achieving a diagnosis and determining what special tests are needed before treatment can begin. Even after a diagnosis is established, the physician must make certain that no other diseases are present. If an anesthetic is anticipated, the surgeon must know the status of the patient’s cardiorespiratory system in order to select the proper anesthetic agents and to preclude complications from the anesthesia. The medical history and the physical examination are the best diagnostic means the physician has at his disposal. You must freely submit to any examinations the doctor wants to make. Efforts are made to avoid all embarrassment to you, and discomfort from the examinations is nil. Various parts of the physical examination will be repeated from time to time to evaluate progress in your condition. (Special examination procedures are discussed in chapters devoted to the various systems.) In pediatric patients or other cases where the patient cannot give the history, a relative may serve as the informant.