Annotations

B.  Ascertain Chief Complaint/Concern, Obtain Medical Psychosocial History, Physical Exam, Laboratory Tests

OBJECTIVE

Establish the reason for the patient’s visit and obtain comprehensive patient data in order to reach a working diagnosis.

ANNOTATION

The clinician should obtain and review the deployment history with the patient to surface potential links to the chief complaint or concern. The patients' beliefs, expectations, and personal circumstances are significant and may play a strong role in the management of their health care.

Some military members are dissatisfied with how clinicians respond to deployment related health concerns. The clinician can validate the patient's deployment related health concerns and communicate care and understanding by completing a thorough and early review of the following:

• All Medical Records
• Medical History and Psychosocial Assessment
• Review of Systems
• Physical and Mental Status Exam
• Routine Test Results
  

Unstable health problems should be addressed immediately before continuing with data collection.

DISCUSSION

In addition to routine medical history and review of systems the following should be assessed:

• Occupational and deployment history, including possible risks, hazards, and exposures to toxic agents
• Combat exposure, including excessively violent or brutal treatment of civilians or prisoners
• Travel history pre-, during, and post-deployment, including immunizations and other prophylactic measures
• Reproductive history including:
  • Infertility or sexual dysfunction among males and females
  • Menstrual history, miscarriages, stillbirths, and congenital malformations among females
• Prescription history, including over-the-counter medications and herbs
• Tobacco, alcohol, and illicit drug use
• Job stability and stress
• Physical and emotional abuse or sexual harassment and assault
• Current support structure, including marital status, family, and friends
• Family, developmental, and psychosocial history
• Sleep habits

Routine Post-Deployment Laboratory Testing may include the following:

• Complete Blood Count (CBC)
• Basic chemistries, including electrolytes, blood urea nitrogen (BUN), creatinine, glucose, and liver function tests
• Urinalysis
• Tuberculin Skin Test (PPD), if not completed within the past 6 months

Standard Health Assessment could include the following:

• Medical and exposure history assessment
• Patient Health Questionnaire (PHQ), a screening tool for depression, somatization, panic disorder, anxiety, alcohol abuse or dependency, binge eating disorder, and bulimia nervosa (see Appendices).
• Post Traumatic Stress Disorder (PTSD) CheckList (PCL), a screening tool specifically designed to assess trauma-related distress that can be self-administered in a brief time period (see Appendices)

REFERENCES

1. Blanchard, E.B., Jones-Alexander, J., Buckley, T.C., and Forneris, C.A. "Psychometric Properties of the PTSD Checklist (PCL)." Behavior Research Therapy. 1996. 34(8): 669-73.
2. Peterson, M.C., Holbrook, J.H., Hales, D.V., et al. "Contributions of the History, Physical Examination, and Laboratory Investigation in Making Medical Diagnoses." Western Journal of Medicine. 1992. 156 (2): 163-5.
3. PHQ References: Spitzer, R.L., Williams, J.B., Kroenke, K., et al. "Utility of a New Procedure for Diagnosing Mental Disorders in Primary Care. The PRIME-MD 1000 Study." Journal of the American Medical Association. 1994. 272: 1749-56.
4. Spitzer, R., Kroenke, K., Williams, J., and the Patient Health Questionnaire Primary Care Study Group. "Validation and Utility of a Self-Report Version of PRIME-MD. The PHQ Primary Care Study." Journal of the American Medical Association. 1999. 282: 1737-44.