Components of a History and Physical

A history and physical contains the following items:

Subjective components: (what the patient discloses)

• Chief Complaint (CC) – the presenting complaint or the reason for the visit (i.e. annual wellness visit)
• History of Present Illness (HPI) – a detailed interview prompted by the Chief Complaint or presenting symptom
• Review of Systems (ROS) – an organ-based structured and subjectively focused survey of symptoms perceived or experienced by the patient
• Past Medical History (PMHx) – medical problems diagnosed prior to the current encounter; can be chronic in nature (i.e. diabetes mellitus type 2) or illnesses previously recovered from (i.e. hepatitis A)
• Past Surgical History (PSHx)– previous surgeries the patient has undergone
• Family History (FamHx) – a medical history of first-degree relatives with an emphasis on parents, grandparents, and siblings
• Social History (SocHx) – occupational, familial, and recreational aspects of the patient’s personal life
• Medications – a detailed list of medications including the dose, frequency, and route of administration
• Allergies – medications that patients cannot tolerate and, whenever possible, the side effect that is caused

Objective components: (what the physician discovers)

• Physical Exam (PE), including vital signs (VS) – process by which a physician examines the body of the patient
• Laboratory Data and Imaging/Studies – obtained from prior records

Assessment components: (what are the diagnoses?)

• Assessment – relate back to the chief complaint and provide supporting documentation in the subjective and objective sections; should focus on the most pressing diagnoses first and list chronic conditions later

Plan components: (what is the treatment plan?)

• Plan – include:
  • non-pharmacologic treatments
  • medications
  • imaging to be ordered
  • laboratory studies to be obtained
  • specialist referrals
  • follow up interval

Components of a Comprehensive Geriatric Assessment

A comprehensive geriatric assessment includes an evaluation of an older individual's functional status, medical conditions (comorbidities), cognition, nutritional status, psychological state, and social support, as well as a review of the patient's medications. In addition to all of the components of a history and physical, a comprehensive geriatric assessment will include a more in-depth social history as well as a functional history and a list of immunizations and preventive services completed by the patient.

The components of a functional history include (useful links are provided):

• Depression screening
• Cognitive screening
• Hearing and visual screening
• Use of ambulatory devices
• Falls and assessment of fall risk
• Nutrition
• Katz Activities of Daily Living (ADLs)
• Lawton Instrumental Activities of Daily Living (IADLs)

Note: For each of the following health screenings, no one tool is recognized above another.

Depression Screening: A standardized depression screening needs to be performed for a functional assessment. Is the patient on an antidepressant? Does psychiatry or psychology follow the patient? If dementia is present, are there other behavior disturbances including depression? Has there been an attempt to perform a gradual dose reduction of any psychotropic medications? A useful screening tool is the Patient Health Questionnaire-2 (PHQ-2). If the score on the PHQ-2 is 3 or greater, the Patient Health Questionnaire-9 (PHQ-9) should be completed. A screening test is offered to asymptomatic people who may or may not have a disease. A diagnostic test is ordered when a patient shows symptoms of a disease and additional evaluation is needed, or if a screening test is positive.

Cognitive Screening: A standard cognitive screening is performed when assessing functional status. For patients with dementia, what is the progression of their cognitive impairment? Are they on dementia-delaying medications (i.e. memantine or donepezil)? Are the dementia-delaying medications still efficacious? Is the type of dementia (Alzheimer’s vs. vascular vs. other) identified? A useful screening tool is the Montreal Cognitive Assessment (MOCA); the instructions for administering the test are also available. If the score on a MOCA is less than 26, this screening test is positive for cognitive impairment and further workup should be performed. Additionally, an extra point should be added to the total score if the patient being screened has less than 12 years of formal education (i.e. did not graduate high school). Applications of the MOCA exam will be discussed in the coming chapters on dementia (Chapter 5), delirium (Chapter 6), and depression (Chapter 7).

Fall risk/reduction: How many falls has the patient had? Does the patient utilize an ambulatory device? Is the patient receiving physical or occupational therapy, or involved in a restorative nursing program? Does home have grab bars in bathroom, handrails on stairs, adequate lighting, and secured rugs? The best predictor of a fall is a history of previous falls. The timed get up and go test (TGUG) is used to assess a person's mobility and requires both static and dynamic balance. It uses the time that a person takes to rise from a chair without assistance, walk three meters, turn around, walk back to the chair, and sit down. If the total time to perform this time is less than 10 seconds, the risk of falling in this patient is considered low. If the time is between 10-20 seconds, the risk of falling is intermediate. If the time required is greater than 20 seconds, the patient is at a high risk of falling. (Chapter 10 discusses falling in more detail and associated contributing factors.)

Hearing/Vision: Does the patient wear hearing aids? Does the patient wear glasses? Is there eye pathology such as glaucoma or macular degeneration present? Is the patient on ophthalmic medications? Do they follow with an audiologist or ophthalmologist? Hearing can be assessed using the whisper test. Hearing impairment is associated with depression, dementia, social isolation, poor self-esteem, and functional disability.

Vision can be assessed using a Snellen eye chart. Visual impairment is not a normal part of aging. Increased incidence is seen over age 75. Visual impairment is associated with an increased risk of falls. Eye exams are recommended at least every 1-2 years over age 65.

Visual impairment can be caused by:

• Cataracts: Clouding of the normally clear lens of the eye. Particularly noticeable at night; bright objects will appear to have halos around them, such as headlights.
• Glaucoma: Caused by damage to the optic nerve, increased intraocular pressure, and results in concentric decreases in vision in affected eyes.
• Macular degeneration: The leading cause of vision loss; can be classified as either “wet” or “dry”. The net result is a loss in the center of the field of vision. In dry macular degeneration, the center of the retina deteriorates. With wet macular degeneration, leaky blood vessels grow under the retina. Macular degeneration presents insidiously with symptoms beginning as wavy lines when looking at objects such as telephone poles and progresses to central vision loss. Blurry vision is a key hallmark of disease presence.
• Diabetic retinopathy: Caused by damage to blood vessels in the retina as a result of osmotic pressure secondary to hyperglycemia.

Nutrition: Does the patient have adequate access to food? Can the patient prepare meals on their own? Is there any concern for food insecurity? Increased appetite is associated with malignancy, hyperthyroidism, uncontrolled diabetes mellitus, malabsorption syndromes, pheochromocytoma, and marked increase in physical activity. Decreased appetite is associated with malignancy, chronic medical illness, COPD, gastrointestinal diseases (i.e. diabetic gastroparesis), depression, opioid and alcohol use or misuse, and iatrogenic causes (i.e. caused by medications).

Preventive Care Screenings and Vaccinations

One of the cornerstones of a comprehensive geriatric assessment is preventive care screening. Most preventive care screenings are not recommended after age 85 – in some cases as early as age 65 or 75 depending on the screening. Patients who meet age criteria for any of the recommended screening tests should be offered these screenings, even when they reside in a long-term care facility (if appropriate). The Agency for Healthcare Research and Quality, a division of the United States Department of Health and Human Services, offers a free online tool available at https://epss.ahrq.gov/ePSS/ (“Search for Recommendations” link on this page) based on the current, evidence-based recommendations of the U.S. Preventive Services Task Force (USPSTF) and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors.

Physicians should assess immunizations including yearly influenza and pneumococcal vaccinations. As a special note, other vaccines are NOT covered by Medicare Part B as routine preventive vaccines. A tetanus booster is covered in the case of appropriate injury. Other preventive vaccines are covered by Medicare Part D, including pertussis, hepatitis B, routine tetanus booster, and zoster.

As discussed in Chapter 2 regarding medications and adverse drug reactions, it is critically important to know all of the medications (prescribed and over-the-counter) medications which a patient is taking. Nearly 50% of patients are on at least one unnecessary medication. Patients in long-term care may be particularly vulnerable to polypharmacy. Providers should focus on medicines with questionable efficacy in elderly patients. Is the statin still useful? Is a proton-pump inhibitor necessary? Are there unnecessary vitamins or supplements? Are there unnecessary prophylaxis medications? (Antibiotics and cranberry for UTI prophylaxis, for example.) A gradual dose reduction or discontinuance of medications should be done to reduce polypharmacy and risk of drug/drug and drug/disease interactions. The importance of medication review cannot be overstated.

Social History: A thorough social history is critical to patient-centered healthcare. Tobacco use should be discussed: Have there been any smoking cessation attempts? Has any pharmacologic therapy tried (i.e. varenicline)? Eating habits should be reviewed. Should mirtazapine or other medications that may stimulate appetite be used? Are stimulants causing weight loss?

Advance Care Planning

Discussion of Advance Directives and goals of care should be undertaken. Physician orders for life sustaining treatment (POLST) form completion is appropriate if the estimated life expectancy is less than one year. (Note: POLST forms may have different names in different states.) Decision-making capacity of the patient must be considered prior to any discussion. End-of-life planning should be done early and discussed often; preferences can and frequently do change. A DNR code status does not mean “do not treat”!

Examples of questions to ask patients regarding goals of care are include:

• Identifying a durable power of attorney who would make medical decisions for the patient in accordance with their wishes if they are unable to
• Reviewed scenarios including artificial nutrition, cardiopulmonary respiration, and desire for hospitalization
• Cardiopulmonary resuscitation in the event of loss of spontaneous circulation or respirations
• Artificial nutrition/hydration (nasogastric or PEG tube)
• Intubation
• Hospitalization
• IV antibiotics
• IV fluids
• Goals of care: To be pain free. To be symptom free. To be made comfortable. Other goals?
• CODE STATUS: Full code? DNR/DNI? DNH?

Cardiopulmonary resuscitation: “In the event of cardiopulmonary failure, do you want CPR?” CPR is associated with a high risk of failure as well as broken ribs and associated trauma. If successfully resuscitated, may not return to prior functional status. Contraindications to CPR include multiple myeloma and fractures. Approximately 15% of patients who receive CPR in the hospital survive to discharge. Chest wall trauma and aspiration occurs in 25-50%. Patients who are successfully resuscitated to a vegetative state is roughly 10%. CPR was never intended for use of patients dying from an expected death from illness.

Intubation: “In the event of cardiopulmonary failure, do you want a tube placed down your throat to help you breathe?” Mechanical ventilation requires placement in the ICU on a ventilator. Some patients elect for a defined trial period with cessation of mechanical ventilation if hope for recovery is futile.

Artificial nutrition and hydration (ANH): Neither have been shown to be beneficial in patients with end-stage dementia nor to reduce skin breakdown. ANH can prevent or improve delirium but carries a risk of aspiration pneumonia equal to, if not greater, than oral intake. All dying patients at some point will lose their appetite and lose their ability to take in food and water. Feeding tubes have a 25% in-hospital mortality and a 60% one-year mortality in patients with advanced dementia. Some patients/families opt for therapeutic feeding which allows patients to enjoy foods of their choice despite known risk of aspiration or other adverse effects. Withholding or withdrawing artificial nutrition is not euthanasia nor physician-assisted suicide. Artificial nutrition is a medical treatment, not “ordinary care”.

Review Questions

1. An 82-year old female presents to her primary care physician with her son complaining of a loss of vision “in the middle of my field of view.” She describes her vision as worsening over the last few years and notes that telephone poles began to look “wavy” while she was driving. She has since stopped driving. She now notes trouble telling light and dark colors apart. Her vision cannot be assessed using a Snellen chart. Her prior visual assessment one year ago was 20/80; the year prior to that she was 20/20. She has no prior medical history and takes no medications. Her vital signs are unremarkable. The remainder of her physical and neurological exam are unremarkable. What is the most likely diagnosis of her visual loss?

A. Cataracts
B. Glaucoma
C. Diabetic retinopathy
D. Macular degeneration

2. A 76-year-old female presents to the office for evaluation of confusion. She was recently started on amitriptyline for depression by her primary care physician. She was treated previously with citalopram and duloxetine following the death of her husband but she did not feel her symptoms improved. She recalled being on this medication in her 40s and requested her physician to prescribe it, which he did. Her medical history is notable for hypertension, chronic kidney disease stage 3, and major depressive disorder. Her other medications include amlodipine and hydrochlorothiazide. Her vital signs and physical exam are unremarkable. Her PHQ-2 score is 4/6. Which of the following is most appropriate to administer after scoring her PHQ-2?

A. PHQ-9
B. Beck Depression Inventory
C. Geriatric Depression Scale
D. Mini-Mental State Exam (MMSE)
E. Montreal Cognitive Assessment (MOCA)

3. What is the difference between a screening test and a diagnostic test?

A. A screening test is performed to determine if a disease is present with a high degree of accuracy.
B. A diagnostic test is offered to asymptomatic people who may or may not have a disease.
C. A screening test is often invasive and requires an in-patient hospital stay.
D. A diagnostic test is offered as a preventive care service.
E. A diagnostic test is ordered when a patient shows symptoms of a disease and additional evaluation is needed.

4. An 84-year-old female presents to the office with her daughter for a Comprehensive Geriatric Assessment. The patient is completely dependent for bathing and has been for some time. Over the past few months she has progressed from occasionally incontinent of urine during the overnight to usually incontinent of urine. She remains continent of stool; she toilets herself (urine and stool) during the day and cleans up after a bowel movement without assistance. The patient has not had any falls since completing a course of physical therapy and learning to use a rolling walker. Her daughter also admits that she used to be able to lay out her mother’s clothes out in the morning, but now really needs to dress her mother in order for her to look her best. She feeds herself and is typically a good eater. How would she be rated on the Katz Activities of Daily Living scale?

A. 1/6 independent
B. 2/6 independent
C. 3/6 independent
D. 4/6 independent

5. The patient from question 17 is also assessed for her IADLs. Her daughter has noted that she has taken over the patient's medications. The patient continues to do her own finances. She no longer drives due to a diagnosis several years earlier of Parkinson's disease and regrettably admits that she depends on her daughter for a ride to the supermarket. The patient never did her own laundry, housekeeping, or food preparation, which her daughter now does. Both note that the patient had a housekeeper in her younger years. She has no problem using the telephone, and proudly shows off her new iPhone X. How would he be rated on the Lawton Instrumental Activities of Daily Living scale?

A. 6/8 independent
B. 5/8 independent
C. 3/8 independent
D. 2/8 independent
E. 1/8 independent

6. A patient received a pneumococcal vaccination at age 66. Upon review of records, it is noted that he received the PPSV-23 (Pneumovax) vaccine. What would the appropriate recommendation be for pneumococcal vaccination at this time?

A. Administer another PPSV-23 (Pneumovax) vaccine today and every five years.
B. Administer PCV-13 (Prevnar) vaccine today.
C. Administer PCV-13 (Prevnar) vaccine today and PPSV-23 (Pneumovax) vaccine in one year.
D. Administer PPSV-23 (Pneumovax) vaccine today, PCV-13 (Prevnar) vaccine in one year and alternate the pneumococcal vaccinations yearly after that.
E. Administer PPSV-23 (Pneumovax) vaccine today and PCV-13 (Prevnar) vaccine in one year.

7. Which of the following correctly states the USPSTF screening guideline for osteoporosis in women?

A. Women aged 65 and older should be screen for osteoporosis every 6 months.
B. Women aged 65 and older should be screened for osteoporosis yearly.
C. Women aged 65 and older should be screened for osteoporosis every 2 years.
D. Women aged 65 and older should be screened for osteoporosis.
E. There is insufficient evidence to recommend screening for osteoporosis in women aged 65 and older.

8. An 86-year-old woman presents to her primary care physician’s office with her daughter for evaluation of weight loss. She had always been moderately obese, but she has steadily lost >10% of her weight over the last 6 months. She lives in a dementia-care assisted living unit. Her medical history is notable for hypertension, hyperlipidemia, congestive heart failure (ejection fraction of 55-60%), coronary artery disease, and diabetes. Her medications include donepezil, memantine, simvastatin, furosemide, metformin, mirtazapine, metoprolol tartrate, lisinopril, and omeprazole. She is incontinent and uses grab bars and a chair in the bathroom for showering. She is dependent for all of her IADLs. She has no recent hospitalizations. She has no history of pressure ulcers or recent infections. Her vital signs are stable and she is afebrile. Her physical exam is notable for upper and lower dentures and is otherwise unremarkable. Which of the following is most accurate with regard to weight loss in this patient?

A. Weight loss in an obese adult is desirable.
B. Weight loss requires evaluation for identifiable and reversible causes.
C. She should be given protein supplements and six small meals daily.
D. Her congestive heart failure is controlled adequately given her weight control.
E. Weight loss is associated with maintenance of function in older adults.

9. Which of the following is the best predictor of a fall?

A. Increased alcohol intake
B. Increasing the number of blood pressure medications
C. History of previous falls
D. Inadequate home lighting
E. Area rugs not being taped to the floor

10. What is the USPSTF guideline for screening for colorectal cancer?

A. The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years with colonoscopy.
B. The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years.
C. The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years with flexible sigmoidoscopy.
D. The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years with screening CT of the colon.
E. The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years with fecal occult blood testing.

11. What is the USPSTF guideline for screening mammogram?

A. The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
B. The USPSTF recommends annual screening mammography for women aged 50 to 74 years.
C. The USPSTF recommends screening mammography for women aged 50 to 74 years every six months.
D. The USPSTF recommends biennial screening mammography for women aged 50 to 80 years.
E. The USPSTF recommends annual screening mammography for women aged 50 to 80 years.

12. What is the USPSTF guideline for screening for hepatitis C virus?

A. The USPSTF recommends offering screening for HCV infection to adults aged 18-79.
B. The USPSTF recommends annual screening for HCV infection to adults born between 1945 and 1965.
C. The USPSTF recommends offering screening for HCV infection to adults born between 1945 and 1965.
D. The USPSTF recommends annual screening for HCV infection to adults aged 18-79.
E. The USPSTF does not recommend screening for HCV infection.

13. Which of the following correctly states the preventive service screening guideline for PSA based on USPSTF recommendations?

A. The USPSTF recommends PSA screening for all adults aged 55-85.
B. The USPSTF recommends PSA screening for all adults aged 55-69.
C. The USPSTF recommends PSA screening for adults aged 55-69 on a case-by-case basis.
D. The USPSTF recommends PSA screening for adults aged 55-85 on a case-by-case basis.
E. The USPSTF recommends against PSA screening for all adults aged 65 and older.

Answers to Review Questions

1. D
2. A
3. E
4. C
5. C
6. B
7. D
8. B
9. C
10. B
11. A
12. A
13. C