were first apparent. Descriptions of the chief complaint that assist the examiner include the following: location of discomfort, quality or quantity of symptoms, frequency, onset, duration, and any associated factors that aggravate or alleviate symptoms. Patients should be asked whether they are currently using medications, supplements, vitamins, home remedies, or poultices. Also, the examiner needs to know whether the patient has shared or borrowed teammates’ or roommates’ prescription medications.

The next sections of a comprehensive history for a patient with a medical condition include past medical history, current health status, and family history. Past history incorporates childhood and adult illnesses as well as accidents and injuries. Keep in mind that adult illnesses also may include psychiatric, obstetrical, or gynecological conditions and surgery. Typically, the patient’s current health status covers alcohol, drug, and tobacco use; exercise; diet; and immunizations. The examiner asks questions about any history of allergies and specific reactions to the antigens and ensures that the patient is up-to-date with routine screening tests, such as Pap smears and breast and testicular self-examinations. It may also be appropriate to explore the reported environmental safety of the home and workplace.

A look into the patient’s family history may provide critical information that can be quite useful in pointing out a susceptibility for a given illness or disease and prove helpful in the examination and care of the patient. Diabetes, heart disease, hypertension, kidney disease, cardiovascular disorders (e.g., deep vein thrombosis [DVT], stroke), allergies, asthma, mental illness, and addictions are all examples of diseases with a genetic tendency. The age, current health, or cause and age at death of immediate family members are also critical factors in determining a family health history. Some physicians add another category, personal and social history, to assist them in understanding their patients better. This category covers a patient’s education, occupation, significant others, home life, daily activities, hobbies, and important beliefs. Although these areas are not necessarily crucial to a specific diagnosis of a given condition, some physicians believe they profoundly affect the overall health and attitude toward wellness in their patients.¹

KEY POINTS

FAMILY HEALTH HISTORY

Conditions and diseases that have a genetic tendency include the following:

• Cardiovascular disorders (deep vein thrombosis [DVT], myocardial infarction, stroke)

Review of Body Systems

The review of body systems (ROS) is the health care provider’s primary focus in the evaluation of medical conditions. Indeed, most health care professionals use the comprehensive medical history and review of body systems in assessing orthopedic injuries as well as medical issues. Traditionally, all systems are reviewed, unlike in an orthopedic assessment, in which a focal examination including only the anatomical area or system believed to be affected is considered. A medical review differs from an orthopedic evaluation, in which the examiner may stop after determining that there is crepitus rather than continuing to look for ligamentous injury. For example, in an orthopedic injury, if the patient has a clearly displaced fractured femur, the examiner does not continue the initial evaluation to determine whether the anterior cruciate ligament (ACL) is intact.

The goal of the review of body systems during an examination for a general medical condition is to enable the clinician to gather enough information to make an intelligent decision about patient referral and, if necessary, referral to a specific type of practitioner.

The review of systems always begins with a general assessment of the patient’s condition: weight and associated changes, fatigue, fever, and any reported sleep disturbances. Then the review continues system by system, starting with the skin and descending from head to toe. When assessing the skin, the examiner looks for obvious rashes, sores, dryness, color change, lumps, or swelling and asks the patient about itching or skin dryness.

A good mnemonic to help remember the order of the first part of the review of systems is HEENT, which stands for head, eyes, ears, nose, and throat. Beginning with signs and symptoms associated with the head, the examiner inquires about the following: headaches, seizures, syncope, tremors, paralysis, or history of a head injury. Essential questions to ask about the eyes concern visual acuity, the need to wear corrective lenses (i.e., glasses, contacts), surgical history that may include procedures that correct vision, date and results of last eye examination, and any history of redness, tearing, diplopia, floaters, pain, dryness, or disease of the eye.

Questions linked to the ears relate to symptoms of tinnitus, vertigo, earaches, and signs of ear dysfunction, such as discharge. Patients with nasal problems or conditions of the accompanying sinuses can present with discharge, sinus pain, itching, sneezing, or stuffiness, whereas mouth and throat problems are manifested by hoarseness, sores, caries, halitosis, or bleeding gums. Pain or stiffness in the neck can indicate an infectious disease, and enlarged glands are palpable signs of a response to changes in the body. Questions about breast discomfort, lumps, or nipple discharge may be relevant if the examiner is given information that points to pathology of the breast tissue. These questions may be pertinent to both genders.

The review of systems continues with the respiratory, cardiovascular, and gastrointestinal systems and follows the same cephalocaudal order. Signs associated with respiratory problems include the presence of excessive sputum, altered respiratory sounds, and hemoptysis. The cardiovascular system encompasses the heart and blood vessels, including blood pressure. Symptoms of cardiovascular anomalies encompass murmurs, dyspnea, chest pain, vasovagal responses, hypertension, and syncope. Gastrointestinal problems may manifest with symptoms such as heartburn, nausea, constipation, and food intolerance. Signs include vomiting; change in frequency, consistency, and/or color of stools; rectal bleeding; diarrhea; gas; and jaundice.²

Next in this descending order of specific systems come the urinary and gynecological systems. Incontinence, pain, discolored urine, or any change in frequency of urination may indicate genitourinary system pathology. A male patient who complains of penile sores, discharge, or hesitancy in voiding should be referred to a physician.

Gynecological disorders include delayed onset of menses, oligomenorrhea, dysmenorrhea, polymenorrhea, severe cramping, late menstrual period, abnormal pain, discharge, and vaginal sores. The examiner questions the patient about these symptoms if gynecological issues are raised when discussing her current health history.

After the cephalocaudal systems review, the evaluation goes on to other prevalent body systems: peripheral vascular, musculoskeletal, neurological, hematological, endocrine, and psychiatric. Important areas to explore include complaints of loss of sensation in the extremities, pitting edema, soreness and swelling in multiple joints, and abnormal fatigue.³ Specific questions pertaining to these systems are discussed later in the appropriate chapters. After the review of all systems, the examiner begins a physical examination of the patient.

Physical Examination

Again, the examiner follows the universally accepted cephalocaudal sequence for the physical examination (Box 2-2). The general survey includes observation of the patient’s apparent state of health, level of consciousness, signs of distress, height and weight, skin color, obvious lesions, and hygiene.⁴ These are noted as the patient enters the examination area. The practitioner continues the physical assessment in the same order as the previously described review of systems, beginning with the vital signs and skin and advancing from the head down the body. The proper evaluation tools should be ready to expedite the examination.

BOX 2-2 SEQUENCE OF SYMPTOM REVIEW AND PHYSICAL EXAMINATION

• Visual disturbances

• History of bleeding

• Heat or cold tolerance

• Weight or energy change

• Testicular pain or swelling

• Urine frequency, volume, color

• Dysuria

Musculoskeletal

• Joint or muscle pain or swelling

• Neurological symptoms

Mental Status

• Eating, sleeping, social habits

• Mood

• Concentration

FMP, First menstrual period; LMP, last menstrual period; LOC, level of consciousness; SOB, shortness of breath.

Vital Signs

Assessment of all vital signs includes height and weight, blood pressure, heart and respiratory rate and rhythm, and body temperature.

Height and Weight

Recording a patient’s height and weight is essential because it provides a baseline for future reference. Height is often critical to athletes but is typically of only mild interest to the health care practitioner. Weight is more critical because a drastic change in weight, whether gain or loss, can indicate a health problem and needs to be followed up in a timely fashion.

Height is typically measured with a stadiometer or, particularly with extremely tall patients, a tape measure fastened to the wall. The patient removes shoes and stands with the back to the stadiometer or wall, placing all weight on the heels. When using a stadiometer, the clinician stands at the side of the patient and raises the stadiometer to the patient’s height. The horizontal arm rests at the crown of the patient’s head. The height measurement is read on the instrument’s vertical scale (Figure 2-1, A). If not using a stadiometer, the athletic trainer must accurately mark increments on the wall or fasten a tape measure to the wall. The athletic trainer stands to the side of the patient (on a stool if necessary) and uses a flat surface on a sagittal plane along the crown of the patient’s head to evenly mark the height measurement on the wall (Figure 2-1, B). Height may be recorded as either centimeters or inches and should be indicated as such in the medical record (see Appendix B for a chart allowing conversion of inches to centimeters).

FIGURE 2-1 A, An athletic trainer measures the patient’s height with a stadiometer. B, The clinician stands to the side of the patient, with clipboard against the wall, when measuring the patient’s height.

Normal body weight is measured without shoes or excessive clothing. Weight is a confidential measurement, so the health care practitioner needs to ensure privacy for the patient during weighing when possible. Weight is typically recorded in medical records in kilograms but may also be recorded in pounds (see Appendix C for a chart allowing conversion of pounds to kilograms). During preseason or excessively warm days, take weight measurements several times each day (preexercise and postexercise) to monitor proper hydration levels and to prevent heat-related illnesses.^5,6 Standardization of measurements can be improved by following the same procedures each time height and weight are measured, for example, measuring both height and weight in the morning and having patients wear a standard attire of gym shorts and T-shirt. More accurate assessments of body composition exclusive of height and weight charts include hydrostatic weighing, skinfold calipers, bioimpedance, and body mass index (BMI) (see Appendix D for a BMI chart).