Chapter 3: Health History

The text delineates the vital distinction between subjective data, which includes symptoms and feelings reported by the patient, and objective data, which comprises physical findings and diagnostic results. It outlines the criteria for determining the scope of assessment, contrasting the Comprehensive Health History used for new patients to strengthen the clinician-patient relationship with the Focused or Problem-Oriented History designed for established patients or urgent care scenarios. A detailed breakdown of the seven components of the Adult Health History is provided, starting with Initial Information and the Chief Complaint, which identifies the primary reason for the visit. The summary explains the intricate process of crafting the History of Present Illness (HPI), emphasizing the need for a chronological narrative that characterizes symptoms using specific attributes such as onset, location, duration, character, aggravating factors, radiation, and severity, often utilizing mnemonics like OLD CARTS or OPQRST. The concept of clinical reasoning is introduced through the documentation of pertinent positives and pertinent negatives to narrow down the differential diagnosis. The summary further details the Past Medical History, including childhood illnesses, adult medical, surgical, obstetric, and psychiatric history, as well as Health Maintenance regarding immunizations and screenings. Considerable attention is given to the Personal and Social History, which encompasses Sexual Orientation and Gender Identity (SOGI), educational and occupational background, and lifestyle habits. Specific clinical tools and frameworks are highlighted, such as the CAGE and AUDIT-C questionnaires for alcohol use disorders, the calculation of pack-years for tobacco history, the 5 Ps model for taking a sexual history, and the FICA tool for assessing spirituality. The Review of Systems (ROS) is described as a scanning method to identify symptoms across body systems that may have been missed. Finally, the text addresses the modification of the clinical interview for diverse settings, including the prioritization of stabilization in Emergency Care, the reliance on secondary sources in the Intensive Care Unit, and the focus on Activities of Daily Living (ADLs) and functional status in Nursing Home and home care environments.