Medical History and Examination

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.

Medical History

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

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.

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