how to write a health history paper

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2 Health History

Learning objectives.

• Describe the purpose of a health history
• Enumerate the components of a health history.
• Discuss how culture, age and ethnicity influence obtaining a health history.
• Demonstrates therapeutic communication when obtaining a  health history.
• Obtain a comprehensive health history
• Document the results of the health history

Overview of this chapter

This chapter presents the importance of a health history as a component of health assessment and the value of a health history obtained from the perspective of a nurse. This chapter will provide information on components of a health history, considerations in obtaining a health history and documentation.

Health History

The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).

Subjective Data

Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). The health history is the subjective data collection portion of the health assessment.

Components of a Health History

The health history obtained by nurses is framed from holistic perspectives of all factors that contributes to the patient’s current health status. The most common way of obtaining information is through an interview, primarily of the patient. When the patient is unable to provide information for various reasons, the nurse may obtain it from secondary sources.

Knowledge Check:

The checklist below provides steps of obtaining a nursing history based that reflects its components such as biographical data, reason for seeking care, history of present illness, past health history, family history, functional assessment, developmental functions and cultural assessment.  Each healthcare facility will have electronic and/or paper forms based on these components.

Interview Guide

Introductory Information: Demographic and Biographic Data

Name/contact information and emergency information

• What is your full name?
• What name do you prefer to be called by?
• What is your address?
• What is your phone number?
• Who can we contact in an emergency? What is their relationship to you? What number can we reach them at?

Birthdate and age

• What is your birthdate?
• What is your age?
• Tell me what gender you identify with.
• What pronouns do you use? (If the person asks you to use a pronoun that you are not familiar with, it is okay for you to respectfully respond, “I am not familiar with that pronoun. Can you tell me more about it?”)
• Do you have any allergies?
• If so, what are you allergic to?
• How do you react to the allergy?
• What do you do to prevent or treat the allergy?

Note: You may need to prompt for information on medications, foods, etc.

Languages spoken and preferred language

• What languages do you speak?
• What language do you prefer to communicate in (verbally and written)?

Note: You may need to inquire and document if the client requires an interpreter.

Relationship status

• Tell me about your relationship status?

Occupation/school status

• What is your occupation? Where do you work?
• Do you go to school?

Resuscitation status

• We ask all clients about their resuscitation status, which refers to medical interventions that are used or not used in the case of an emergency (such as if your heart or breathing stops). You may need more time to think about this, and you may want to speak with someone you trust like a family member or friend. You should also know that you can change your mind. At this point, if any of this happens, would you like us to intervene?  

Main Health Needs (Reasons for Seeking Care)

Presenting to a clinic or a hospital emergency or urgent care (first point of contact)

• Tell me about what brought you here today.
• Tell me more.
• How is that affecting you?

Already admitted, and you are starting your shift

• Tell me about your main health concerns today.

The PQRSTU Mnemonic

Provocative

• What makes your pain worse?
• What makes your pain feel better?
• What does the pain feel like?
• How bad is your pain?
• Where do you feel the pain?
• Point to where you feel the pain.
• Does the pain move around?
• Do you feel the pain elsewhere?
• How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you’ve ever experienced?
• When did the pain start?
• What were you doing when the pain started?
• Where were you when the pain started?
• Is the pain constant or does it come and go?
• If the pain is intermittent, when did it last occur?
• How long does the pain last?
• Have you taken anything to help relieve the pain?
• Have you tried any treatments at home for the pain?

Understanding

• What do you think is causing the pain?

Current and Past Health

Current health

• Are there any other issues affecting your current health?

Childhood illnesses

• Tell me about any significant childhood illnesses that you had.
• When did it occur?
• How did it affect you?
• How did it affect your day-to-day life?
• Were you hospitalized? Where? How was it treated?
• Who was the treating practitioner?
• Did you experience any complications?
• Did it result in a disability?

Chronic illnesses

• Tell me about any chronic illnesses you currently have or have had (e.g., cancer, cardiac, hypertension, diabetes, respiratory, arthritis).
• How has the illness affected you?
• How do you cope with the illness?
• When were you diagnosed?
• How was the illness being treated?
• Have you been hospitalized? Where?
• Have you experienced any complications?
• Has the illness resulted in a disability?
• How does the illness affect your day-to-day life?

Acute illnesses, accidents, or injuries

• Tell me about any acute illnesses that you have had.
• Tell me about any accidents or injuries you currently have or have had.
• Were you hospitalized? Where?
• How was it treated?
• Has it resulted in a disability?

Obstetrical health

• Have you ever been pregnant?
• Do you have plans to get pregnant in the future?
• Tell me about your pregnancies.
• Have you ever had difficulty conceiving?
• How was your labour and delivery?
• Tell me about your postpartum experience.
• Were there any issues or complications?

Mental Health and Mental Illnesses

Mental health is an important part of our lives and so I ask all clients about their mental health and any concerns or illnesses they may have.

Mental health

• Tell me about your mental health.
• Tell me about the stress in your life.
• How does stress affect you?
• How do you cope with this stress? (this may include positive or negative coping strategies.)
• Have you experienced a loss in your life or a death that is meaningful to you?
• Have you had a recent breakup or divorce?
• Have you recently lost your job or been off work?
• Have you recently had any legal issues?
• Have you purchased any weapons?

Mental illness

• How does that illness affect you?
• How does that illness affect your day-to-day life?
• What resources do you draw upon to cope with your illness?
• Tell me about your treatment (e.g., medications, counselling).
• Do you have any concerns that have not been addressed related to your illness?

Functional Health

• Tell me about your diet.
• What foods do you eat?
• What fluids do you drink? (Probe about caffeinated beverages, pop, and energy drinks.)
• What have you consumed in the last 24 hours? Is this typical of your usual eating pattern?
• Do you purchase and prepare your own meals?
• Tell me about your appetite. Have you had any changes in your appetite?
• Do you have any goals related to your nutrition?
• Do you have the financial capacity to purchase the foods you want to eat?
• Do you have the knowledge and time to prepare the meals you want to eat?

Elimination

• How often do you urinate each day?
• What colour is it (amber, clear, dark)?
• Have you noticed a strong odour?
• How often do you have a bowel movement?
• What colour is it (brown, black, grey)?
• Is it hard or soft?
• Do you have any problems with constipation or diarrhea? If so, how do you treat it?
• Do you take laxatives or stool softeners?

Sleep and rest

• Tell me about your sleep routine.
• How much do you sleep?
• Do you wake up at all?
• Do you feel rested when you wake? What do you do before you go to bed (e.g., use the phone, watch TV, read)?
• Do you take any sleep aids?
• Do you have any rests during the day?

Mobility, activity, exercise

• Tell me about your ability to move around.
• Do you have any problems sitting up, standing up or walking?
• Do you use any mobility aids (e.g., cane, walker, wheelchair)?
• Tell me about the activity and/or exercise that you engage in. What type? How frequent? For how long?

Violence and trauma

• Many clients experience violence or trauma in their lives. Can you tell me about any violence or trauma in your life?
• How has it affected you?
• Tell me about the ways you have coped with it.
• Have you ever talked with anyone about it before?
• Would you like to talk with someone?

Relationships and resources

• Tell me about the most influential relationships in your life.
• Tell me about the relationships you have with your family.
• Tell me about the relationships you have with your friends.
• Tell me about the relationships you have with any other people.
• How do these relationships influence your day-to-day life? Your health and illness?
• Who are the people that you talk to when you require support or are struggling in your life?

Intimate and sexual relationships

• I always ask clients about their intimate and sexual relationships. To start, tell me about what you think is important for me to know about your intimate and sexual relationships.
• Tell me about the ways that you ensure your safety when engaging in intimate and sexual practices.
• Do you have any concerns about your safety?

Substance use and abuse

• To better understand a client’s overall health, I ask everyone about substance use such as tobacco, herbal shisha, alcohol, cannabis, and illegal drugs.
• Do you or have you ever used any tobacco products (e.g., cigarettes, pipes, vaporizers, hookah)? If so, how much?
• When did you first start? If you used to use, when did you quit?
• Do you drink alcohol or have you ever? If so, how often do you drink?
• How many drinks do you have when you drink?
• When did you first start drinking? If you used to drink, when did you quit?
• Do you use or have you used any cannabis products? If so, how do you use them? How often do you use them?
• When did you first start using them?
• Do you purchase them from a regulated or unregulated place?
• If you used to use cannabis, when did you quit?
• Do you use any illegal drugs? If so, what type? How often do you use them?
• Tell me about the ways that you ensure your safety when using any of these substances.
• Have you ever felt you had a problem with any of these substances?
• Do you want to quit any of these substances?
• Have you ever tried to quit?

Environmental health and home/occupational/school health

• Tell me about any factors in your environment that may affect your health. Do you have any concerns about how your environment is affecting your health?
• Tell me about your home. Do you have any concerns about safety in your home or neighbourhood?
• Tell me about your workplace and/or school environment.
• What activities are you involved in or what does your day look like?

Self-concept and self-esteem

• Tell me what makes you who you are.
• Are you satisfied about where you are in your life?
• Can you share with me your life goals?
• Please explain.
• Tell me about how you take care of yourself and manage your home.
• Do you have sufficient finances to pay your bills and purchase food, medications, and other needed items?
• Do you have any current or future concerns about being able to function independently?

Preventive Treatments and Examinations  

Medications

• Do you have the most current list of your medications?
• Do you have your medications with you? (If not, you should ask them to list each medication they are prescribed and if they know, the dose and frequency.)
• Can you tell me why you take this medication?
• How long have you been taking this medication?
• Do you take the medications as prescribed? (If they answer “no” or “sometimes,” ask them to tell you the reasons for not taking the medications as prescribed.)

Examination and diagnostic dates

• When was the last time you saw [name the primary care provider, nurse or specialist]?
• Can you share with me why you saw them?
• When was the last time you had your [name screening] tested?
• Do you know what the results were?

Vaccinations

• Can you tell me about your immunization status?
• Can you tell me what immunizations you have had, the dates you received them, and any significant reactions?
• Do you have your immunization record?
• When was your last flu vaccine?

If the client’s immunizations are not up-to-date or you noted vaccination hesitancy, you may ask:

• Can you tell me the reasons that your immunizations are not up-to-date?
• Can you tell me why you are hesitant to receive immunizations. (You may need to explore this further.)  

Family Health

• Do they have any chronic or acute diseases (e.g., cardiac, cancer, mental health issues)?
• If so, do you know the cause of death?
• And at what age did they die?
• Has anyone been sick recently?
• If so, do you know the cause?
• What symptoms have they had?
• Have you been around anyone else who was sick recently (e.g., at work, at school, in a location that involved a close encounter such as a plane or an office)?

Cultural Health

• I am interested in your cultural background as it relates to your health. Can you share with me what is important about your cultural background that will help me care for you?
• How does that affect your health and illnesses?
• Is there anything else you want to share about how these factors act as resources in your life?

Learning Resource:  Open the link below for more detailed information.

The Complete Subjective Health Assessment

Cultural factors in obtaining a health history

When interviewing a patient the nurse must be aware of cultural barriers and preferences in order to collect significant and complete subjective data.. For example due  to age, culture, or ethnicity, some patients may believe that pain is to be expected and endured. The patient may not identify their pain as worthy of report unless the nurse is sensitive to this potential barrier of care. Due to age, culture or ethnicity, some patients may feel uncomfortable discussing sexual health. For example, where HIV is epidemic, it is the nurse’s responsibility (along with all other healthcare personal) to uncover risk factors that can address safety and early treatment for STIs (sexually transmitted diseases). Culture can have many meanings. Some of the many aspects that nurses need to be aware of that will impact information obtained in a health history include gender  identity,  religion,  geographical region, and many diverse factors.   The nurse must be open to learning about various cultures and ethnicity and be comfortable in initiating a cultural assessment, and use this knowledge to enhance communication to obtain the most accurate health history.

Health history and therapeutic communication

Needless to say, therapeutic communication techniques are essential in obtaining a health history. However, due to many reasons, healthcare professionals, including nurses, oftentimes fail to establish a therapeutic relationship or to deliver therapeutic communication. The following are examples :

• Have you ever been to see a healthcare provider and when they walk in the room they are not looking at you but are looking at the chart, or tapping on a computer.
• Have you ever felt rushed by their questions, like they are in a hurry and need to move on to the next patient?
• Have you ever had the healthcare provider give you a diagnosis, provide you with a treatment and you left with a prescription but you didn’t grasp the entire explanation?

The nurse should apply communication and interpersonal skills to create, maintain, and terminate a nurse-client relationship. [] Nurses and other healthcare professionals need to use therapeutic communication techniques at all times.

Open the link below for more detailed information

Therapeutic Communication

Documentation of Health History:

The patient’s health history is initially obtained during admission or initial visit, and constantly updated with subsequent interactions or visits. Documentation of information obtained during the nurse-patient interview, and/or secondary sources will need to be documented on a format that the healthcare facility uses. Nowadays, most healthcare facilities use electronic health records (EHR). EHRs are accessed by various members of the healthcare team in real-time, and this indicates that information obtained can be recorded during the interview process as well. The nurse needs to develop the competency to maintain therapeutic communication techniques while attending to the electronic health record keeping.  Healthcare facilities use different documentation systems. Nurses will need to learn facility specific documentation system, whether electronic or paper, but the contents of a patient history will largely be similar.

Learning Exercises

LaPierre, D. (2010). Clinical assessment. Sharing in health.ca:open access training in healthcare.Retrieved at http://www.sharinginhealth.ca/clinical_assessment/clinical_assessment.html

Nursing Documentation https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/QMP/NurseDocumentationPPT.pdf

Sharma, N and Gupta, V ( 2021). Therapeutic Communication. https://www.statpearls.com/articlelibrary/viewarticle/127665/?utm_source=pubmed&utm_campaign=reviews&utm_content=127665#

Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2015). Fundamentals of nursing: The art and science of person-centered nursing care(8th ed.). Philadelphia: Wolters Kluwer Health.

Wilson, S., Giddens, J., (2013). Health assessment for nursing

Health Assessment Guide for Nurses Copyright © by Ching-Chuen Feng; Michelle Agostini; and Raquel Bertiz is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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History and Physical Examination (H&P) Examples

The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations. The students have granted permission to have these H&Ps posted on the website as examples.

H&P 1 “77 yo woman – swelling of tongue and difficulty breathing and swallowing”

H&P 2 “47 yo woman – abdominal pain”

H&P 3 “56 yo man – shortness of breath”

H&P 4 “82 yo man – new onset of fever, HTN, rigidity and altered mental status”

H&P 5 “76 yo man – chest pain”

H&P 6 “24 yo man – bilateral knee pain”

H&P 7 “51 yo man – dyspnea on exertion”

H&P 8 “47 yo woman – chest pain, SOB “

H&P 9 “61 yo man – increased weakness and slurred speech”

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How to Write a Good Medical History

Last Updated: January 25, 2022 References

wikiHow is a “wiki,” similar to Wikipedia, which means that many of our articles are co-written by multiple authors. To create this article, 9 people, some anonymous, worked to edit and improve it over time. This article has been viewed 95,169 times. Learn more...

Nearly every encounter between medical personnel and a patient includes taking a medical history. The level of detail the history contains depends on the patient's chief complaint and whether time is a factor. When there is time for a complete history, it can include primary, secondary and tertiary histories of the chief complaint, a review of the patient's symptoms, and a past medical history.

• Ask the patient to expand on the chief complaint or complaints. In particular, ask about anything that the patient was unclear about or that you don't understand.
• Get specific numbers for things like how long the patient has had the symptoms or how much pain, on a scale of 0 to 10, the patient is experiencing.
• Record, as accurately as you can, what the patient tells you. Don't add your interpretation to what you hear. [2] X Research source

• The patient may not recognize that associated symptoms are related to the chief complaint and may not even view them as symptoms. You will have to interpret what you hear to complete this section of the medical history.

• General constitution
• Skin and breasts
• Eyes, ears, nose, throat and mouth
• Cardiovascular system
• Respiratory system
• Gastrointestinal system
• Genitals and urinary system
• Musculoskeletal system
• Neurological or psychological symptoms
• Immunologic, lymphatic and endocrine system

• Allergies and drug reactions
• Current medications, including over-the-counter drugs
• Current and past medical or psychiatric illnesses or conditions
• Past hospitalizations
• Immunization status
• Use of tobacco, alcohol or recreational drugs
• Reproductive status (if female), including date of last menstrual period, last gynecological exam, pregnancies and contraception method
• Information on children
• Family status, including whether the patient is married, who the patient lives with and other relationships. Include questions about the patient's current sexual activity and history.
• Occupation, particularly if it includes exposure to hazardous materials

Expert Q&A

You might also like.

• ↑ https://meded.ucsd.edu/clinicalmed/write.htm
• ↑ https://med.ucf.edu/media/2018/08/Guide-to-the-Comprehensive-Pediatric-H-and-P-Write-up.pdf
• ↑ https://meded.ucsd.edu/clinicalmed/ros.htm
• ↑ https://www.rch.org.au/clinicalguide/guideline_index/Writing_a_good_medical_report/
• https://en.wikipedia.org/wiki/Medical_history

About This Article

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The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment.

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Taking a comprehensive health history: learning through practice and reflection

Affiliation.

• 1 Registered Advanced Nurse Practitioner (Cardiology) and Registered Nurse Prescriber (Cardiology), Tallaght Hospital (a Trinity College Dublin Teaching Hospital), Dublin, Republic of Ireland.
• PMID: 29034702
• DOI: 10.12968/bjon.2017.26.18.1033

Taking a comprehensive health history is a core competency of the advanced nursing role. The purpose of the health history is to source important and intimate knowledge about the patient and allow the nurse and patient to establish a therapeutic relationship. Reflective practice, a core value of nursing in Ireland, means learning from experience. This article demonstrates how a recorded comprehensive health history simulation, coupled with reflection, provided insight into an advanced nurse practitioner's history-taking skills, thereby enhancing clinical practice.

Keywords: Advanced nursing; Assessment; Clinical history taking; Core values; Reflection.

• Advanced Practice Nursing
• Documentation
• Medical History Taking / methods*
• Nurse-Patient Relations
• Nursing Assessment / methods*

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History and Physical Examination

Introduction.

Taking a careful and complete history and performing a thorough physical examination are hallmarks of the good internist and one of the distinguishing characteristics of a master clinician. The initial visit sets the tone of the immediate and future relationship with the patient and begins the process of diagnosing and managing the illness; it is a dynamic encounter, with each of the patient's responses stimulating further probing and forming of diagnostic hypotheses. The physician must be attentive to the patient's story, piecing together each bit of evidence to form a tentative preliminary diagnosis and differential diagnoses. Nothing should escape the eyes and ears of a watchful diagnostician. History taking is more than information gathering: it affords the opportunity to decipher the patient's body language as the inquiry proceeds. At this stage, no symptom or circumstance should be disregarded. With an understanding of biology and medicine coupled with past experience, the physician tries to connect the salient parts of the patient's story to develop a plausible explanation of the physiologic or pathologic events that lead to illness.

Although striving for a single diagnosis, the physician should realize that more than one disease may be present and that rare diseases are diagnosed only by those who consider them. Nevertheless, the maxim “uncommon presentations of common diseases are more frequent than common presentations of uncommon diseases” is likely to be true. It is important to continue both to gather information and to be open to reforming the diagnostic hypothesis as more information becomes available. Premature judgment or the failure to continue considering reasonable alternatives after an initial diagnosis is made is the single most common diagnostic error. 1 , 2 In the field of decision science, these failures are postulated to arise from “cognitive dispositions to respond” and include several of the biases in judgment or reasoning defined in Table 16-1 . 3 It is hypothesized that a greater awareness of these prejudices among clinicians may facilitate “cognitive debiasing,” thereby reducing the frequency of these common errors of reasoning. 4 An alternative or potential complementary approach is to use decision-support software to expand the differential diagnosis and avoid overlooking unusual or severe conditions. 5

Selected Biases in Judgment or Reasoning

Bayes theorem implies that diagnostic tests will have a higher yield if the prior probability of the diagnosis is high (also called pretest probability). Specific details from the history raise the probability of different diagnoses and direct further tests in a productive manner. Further diagnostic investigations—imaging, blood tests, pulmonary function studies, and even parts of the physical examination—depend on the history. Historical clues raise or lower probabilities, thereby improving the value of subsequent questions and evaluations. Test results plus findings from the history and physical examination may confirm or refute the main and differential diagnoses, setting up either a management plan or the need for an alternative hypothesis.

At the end of the initial evaluation, the assessment and plan should identify problems and a course of action that takes into account the patient's concerns and questions. The patient should feel satisfaction that the physician has done a thorough job of exploring his or her complaints, has provided a plausible explanation for them, and has planned a reasonable course of action.

Electronic Documentation

The electronic medical record now allows documents of higher quality than written records, owing to improved organization, increased readability, use of supplementary material, and better comparisons. It eliminates poor handwriting and lost or misplaced information. Additional benefits include cost savings for storage, easy accessibility, and quick transfer to another health care provider. 6 The electronic medical record facilitates a coordinated team approach and reduces duplication of tests. Patients with complicated illnesses often have several different physicians, and electronic records can make it easier for one team to follow what another team is doing. Easy access to a complete record is especially important in emergency situations for physicians who are unfamiliar with the presenting patient. Electronic medication lists and reminders can save time and reduce errors. Electronic prescriptions provide greater patient safety.

Writing directly into the medical record, or initially through a word processing program, makes a cogent summary and chronological story easier to produce. The ability to insert information where it belongs helps maintain a congruous timeline. Spelling and grammar checks and autocorrection of abbreviations should make the finished report an easily readable document.

The disadvantages of electronic medical records include “information overload” and potential loss of privacy. Software downtime can be crippling. Learning how to use specific applications and developing typing skills may require training. Most word processing software used in electronic medical records is less efficient than commonly used commercial word processing software.

The “cut-and-paste” technique, beginning where the last visit left off, both saves time and ensures that ongoing problems are not overlooked. The problem with the cut-and-paste approach is that too much information may get deposited and duplicated in the medical record, including information irrelevant to the purpose of the consultation. Such excess text can at times replace essential information and impair easy understanding and critical reasoning. Cutting and pasting of information from consultants and other involved persons should never substitute for one's own primary history gathering or clinical thought. Cutting and pasting information gathered by someone else implies agreement with the statements. Proofreading is essential, especially of electronic prescriptions, because of the different doses and means of delivery of certain drugs.

Transfer of electronic medical information is not foolproof. Patients and physicians find it easy and convenient to communicate and transfer information by email, but there is a risk that the record of these interchanges may fail to be placed in the patient's permanent medical record, be intentionally or unintentionally intercepted leading to loss of privacy, or otherwise cause misunderstanding. Physicians may send patients electronic copies of their record, but if these are in a word processing format, patients could alter the record for secondary gain. Many of these concerns could have medicolegal consequences. 6

Communication Skills

The ability to listen skillfully, and to communicate clearly and empathetically with the patient, is the foundation for the physician-patient relationship. Communicating effectively with patients and peers underlies the success of a physician. The physician's communication should be objective, nonjudgmental, and empathic. Physicians are often better at obtaining medical information than they are at understanding how that information affects the patients. 7 Communication contains both verbal and nonverbal interactions. 8 A calm atmosphere, relaxed setting, and ample time are essential, particularly when disclosing bad news, 9 but even then, a physician with good communication skills should be able to make the patient pleased that she or he saw the physician. This can be accomplished by always stating the truth but by cushioning ominous information with hope. When realistic, the physician might say, for example, that the cancer was caught early, provide reassurance about a probable good outcome, or suggest a new and improved therapy.

The old-fashioned tutorial approach of learning how to be a good physician had many shortcomings; students, residents, and fellows learned medicine as apprentices in “a catch-as-catch-can” manner. More recently, however, scientific testing and social psychological analysis have uncovered egregious flaws in how physicians obtain, sort out, and evaluate diagnostic information. Sir William Osler used to tell students to “listen to the patient, he (or she) will tell you the diagnosis.” Today—instead—as Dr. J. Groopman points out in his excellent book, How Doctors Think , physicians interrupt the patient's initial history in just 16 seconds and frequently thereafter, make snap judgments, and fall into cognitive traps that are much more likely than factual ignorance to lead to medical errors. 10 New practice guidelines from evidence-based research help steer a correct diagnostic course, but the presence of overlapping diagnoses, unusual symptoms, and uncommon diseases requires wise and discerning physicians, not inflexible algorithms.

Medical Interview

There is much more to the medical history than a recitation of questions and recording of answers. Instead, the medical interview has been defined as the entire medium of patient-physician interaction. 11 From this interactive experience, both physicians and patients learn about each other: the knowledge shared and feelings imparted influence subsequent trust, understanding, concern, and adherence to the health plan. Experience is valuable in the acquisition of clinical pattern recognition and in accumulating clinical knowledge. Although interviewing skills can be systematically learned, 12 acquiring the art of adept history taking and physical examination is a lifelong process that is incrementally improved by careful practice.

The main purposes of the medical interview are to (1) gather useful information, (2) develop rapport, (3) respond to concerns, and (4) educate the patient. The ease with which patients can access medical information may lead to a more active role on their part; patients may be well informed or misinformed about their actual or perceived diagnoses. Whatever their knowledge, most patients want to be accurately informed about their condition and to be involved in the deliberations and decision making. 13 At the same time they generally want their physician to direct their health care in a reasoned manner, which entails taking into account the patients' background knowledge, prejudices, and culture in a sensitive manner. This means the physician's plan should take into account the individuality of the patient.

Encouraging the patient to take the lead in expressing his or her symptoms and relationships to these symptoms forms the basis for the patient-centered interview 14 and develops appropriate rapport. Even in this era of reliance on laboratory studies, Platt's original claim 15 that a diagnosis can be obtained by history taking alone in most patients has been reaffirmed by several subsequent investigations. 16 , 17 , 18

Chief Complaint and Present Illness

The medical history has traditionally been subdivided into the chief complaint; present, past, family, and social histories; and systems review. Because of its relevance and importance in the evaluation of patients with known or suspected pulmonary diseases, the occupational history is included as a separate component of the social history. Travel history, also included in the social history, is helpful in diagnosing certain lung diseases.

Only the chief complaint stands alone as a discrete response to a single question. It is generally recommended that the chief complaint be written in the patient's own words, lest the physician's interpretation be substituted prematurely for the patient's unique concern. Each chief complaint must be explored in detail, and the resulting aggregate of information constitutes the history of the present illness. The various elements of the remainder of the history are sorted into their proper categories after the interview has been completed. The resulting history of present illness is a cogent chronological story that incorporates all the facts and their relationships that support the preliminary diagnosis and differential diagnoses. Although an open-ended and free-flowing encounter, the interview still should be focused and organized. Each new question is often linked to the answer to the previous one. At the end the review of systems is a series of questions designed to cover previously unexamined territory.

Even as the clinician fulfills the roles of information gatherer and detective, a more complex process is occurring in which a patient's verbal and nonverbal responses to symptom queries provide a personal and often explanatory narrative that may encapsulate unique and individual aspects of illness. These may include the experience of illness and its relationship to any and all aspects of the patient's life. The emerging field of narrative medicine highlights the effects such storytelling has on patients and providers, and its ability to enrich the physician-patient relationship and the clinical experience. 19 , 20

Major Pulmonary Symptoms

Because dyspnea, cough, and chest pain are among the most common reasons for patients to visit physicians, and because these symptoms may result from serious underlying chest disease, careful questioning is needed to establish their etiology and significance. The anatomic and pathophysiologic basis of these cardinal symptoms is provided in Chapters 29 to 31Chapter 29Chapter 30Chapter 31. To aid the interviewer in obtaining a medical history, a brief overview of these three common presenting symptoms and a related one, hemoptysis, is provided in this section.

When a healthy person increases his or her level of physical activity sufficiently, an awareness of breathing emerges; if the severity of activity increases even further, the sensation becomes progressively more unpleasant, until it typically compels the individual to slow down or stop. 21 Although dyspnea, shortness of breath, and breathlessness are often used interchangeably, as in Chapter 29, some purists use the term dyspnea only when the symptom is abnormal, which implies that the awareness is disproportionate to the stimulus and that the sensation is pathologic. Many patients describe their breathing discomfort as “breathlessness,” but many others complain of “tightness,” “choking,” being “unable to take a deep breath,” “suffocating,” being “unable get enough air,” or occasionally even “tiredness.”

The mechanisms that underlie the sensation of dyspnea remain poorly understood and are reviewed in Chapter 29. In contrast to pain and cough, for which specific receptors and neural pathways have been identified, similar detailed knowledge is lacking for dyspnea, although evidence is mounting that links the symptom with pain. 21 , 22 Studies of the neurophysiology of dyspnea are further complicated by the lack of objective tools to quantify a subjective sensation with interindividual variation. Rating instruments—such as the Borg scale 23 and questionnaires, such as the British Medical Research Council questionnaire 24 and Pulmonary Functional Status and Dyspnea Questionnaire 25 —have been validated as useful in measuring dyspnea. Self-administered, computerized versions of the Transitional Dyspnea Index and Multidimensional Baseline Dyspnea Index appear to be at least as good as interview questioning for this assessment. 26 Progress, though, is being made: recent studies have clearly shown that dyspnea during exercise in patients with chronic obstructive pulmonary disease (COPD) is closely linked to dynamic lung hyperinflation. 27

Clinical Features.

Patients with respiratory, cardiac, hematologic, metabolic, and neuromuscular disorders may all complain of dyspnea. A careful and detailed history is necessary to uncover the cause of the sensation. In addition, it is important to document the impact of the symptom on the patient's daily activities and to be alert to the “decreased activity phenomenon.” The latter describes patients who say their dyspnea has not worsened, but only because they now walk more slowly or no longer climb stairs or engage in athletic activities. Sometimes this slowing down is so gradual, patients may be unaware or attribute it to aging. Assessing the activity required to bring about the dyspnea is important. How many stairs can be climbed before stopping? How far can someone walk on level ground at her or his own pace without stopping? Does talking on the phone, getting dressed, or eating cause dyspnea? Is the patient short of breath at rest?

The course over time should be noted. Sudden dyspnea without an obvious provocation suggests pulmonary embolism or pneumothorax, although myocardial ischemia and asthma also may have a rapid onset. Dyspnea caused by cigarette smoke, dusts, molds, perfumes, newly cut grass, cats, and strong odors is characteristic of the increased bronchial reactivity seen in asthma. Associated features, such as wheezing and the presence and type of chest tightness or pain, are important clues. Worsening dyspnea with cough producing increased quantities of purulent sputum over 1 to 3 days characterizes an exacerbation of COPD.

Special types of dyspnea are sufficiently distinctive to warrant separate designations. Episodes of breathlessness that wake persons from a sound sleep, paroxysmal nocturnal dyspnea, usually denote left ventricular failure but may also occur in patients with chronic pulmonary diseases because of pooling of secretions, gravity-induced decreases in lung volumes, sleep-induced increases in airflow resistance, or nocturnal aspiration. Orthopnea, the onset or worsening of dyspnea on assuming the supine position, like paroxysmal nocturnal dyspnea, is found in patients with heart disease and chronic lung disease. Measurement of amino-terminal pro-B-type natriuretic peptide has proved useful in differentiating between a cardiac and a respiratory origin in patients with dyspnea. 28

The inability to assume the supine position ( instant orthopnea ) is characteristic of paralysis of both leaves of the diaphragm. Dyspnea soon after assuming the supine position also may be associated with other conditions, such as arteriovenous malformation, bronchiectasis, and lung abscess. Platypnea, which denotes dyspnea in the upright position, and trepopnea, an even rarer form of dyspnea that develops in either the right or the left lateral decubitus position, suggest lung vascular shunting. Both the terms hyperpnea, an increase in minute ventilation, and hyperventilation, an increase in alveolar ventilation in excess of carbon dioxide production, indicate that ventilation is abnormally increased. Neither term, however, carries any implication about the presence or absence of dyspnea.

The quantity of bronchial secretions produced each day by a nonsmoking healthy adult is not precisely known, but it is sufficiently small to be removed by mucociliary action alone: healthy persons seldom cough. 29 As described in Chapter 30, coughing is an essential mechanism that protects the airways from the adverse effects of inhaled noxious substances and defends the lungs by clearing excess secretions. 30 Coughing can be occasional, transient, and unimportant. By contrast, it may indicate the presence of severe intrathoracic disease.

Most episodes of coughing are associated with short-lived upper respiratory tract infections or allergies, and patients, recognizing this, seldom visit their physicians for this type of cough. Nevertheless, cough is the most common complaint for which patients seek medical attention and the second most common reason for having a general medical examination. 31 Physicians should realize that when patients seek their help for cough, it is often out of concern for something new, different, and alarming about the symptom. The essential first step in evaluating a patient with cough is to obtain a thorough history, paying particular attention to the following aspects: acute or chronic, productive or nonproductive, character, time relationships, type and quantity of sputum, and associated features. It is noteworthy that, of the various components of the workup used by the authors of a systematic anatomic investigation to determine the causes of chronic cough, the medical history alone led to the correct diagnosis in 70% of patients. 31

Acute coughing is frequently associated with nasopharyngitis, laryngotracheobronchitis, or other, usually virus-induced, upper respiratory tract infections. Less commonly, it may be the chief manifestation heralding the onset of viral or bacterial bronchopulmonary infection or the inhalation of allergenic or irritating substances. The causes of cough that persisted for 3 weeks or longer in 102 patients were postnasal drip (41%), asthma (24%), gastroesophageal reflux (21%), chronic bronchitis (5%), and bronchiectasis (4%). 31 Other important though less common conditions include eosinophilic bronchitis 32 and the use of angiotensin-converting enzyme inhibitors. 33 In 1999 the importance of the “big three”—postnasal drip, asthma, and gastroesophageal reflux—was verified by the results of another survey of the causes of chronic cough. 34 Not everyone agrees, however, and some experts claim that emphasis on the top three conditions is unwarranted and moreover that it stifles interest and research into other important causes and mechanisms of chronic cough. 35

A careful history of patients with cough lasting at least 3 months revealed that nearly all the patients misdiagnosed as “psychogenic” had one of the conditions listed previously for chronic cough. 36 Even cough that is made worse with psychological stress is often caused by underlying lung disease. Patients with exaggerated cough responses or habitual cough may have a “psychogenic” component; therefore, even when chronic cough has a pulmonary cause, it may respond to behavioral modification. 37

Most physicians have heard the ancient diagnostic axiom, which is still true, that any change in the character or pattern of a chronic cough in a smoker demands a prompt chest radiographic evaluation for lung cancer. Less well known is that cough may be the sole presenting manifestation of asthma 38 or gastroesophageal reflux disease. 39

In low-income countries, where the majority of the global population lives, cough, usually productive but not always, of 3 weeks or longer has been the traditional (and reliable) clinical marker of possible pulmonary tuberculosis that should trigger examination of sputum specimens for Mycobacterium tuberculosis. Revised recommendations by tuberculosis experts now include cough of “2 or 3 weeks,” or longer, as an indication for sputum examination. 40

Among the many complications of persistent or recurrent cough are tussive syncope; retinal vessel rupture; persistent headache; chest wall and abdominal muscle strains, including the development of abdominal wall hernia 41 ; and even rib fractures. Severe chronic cough may create devastating personal distress, causing patients to restrict their social and professional activities.

The expectoration of any amount of blood denotes hemoptysis. Every patient with new-onset or appreciable hemoptysis deserves a thorough diagnostic evaluation, which generally includes computed tomography (CT) of the thorax and bronchoscopy. For centuries, hemoptysis was considered pathognomonic of pulmonary tuberculosis, a view that is summarized in the Hippocratic aphorism “the spitting of pus follows the spitting of blood, consumption follows the spitting of this, and death follows consumption.” 42 The frequency of the different conditions that cause hemoptysis depend to a large extent on the population studied, but bronchitis, lung cancer, tuberculosis, and bronchiectasis are usually the most common causes. 43 , 44 , 45 These are also the leading causes of massive hemoptysis (defined in various series as >200 or >600 mL of blood in 24 hours). Lung cancer and bronchitis usually cause mild to moderate bleeding, whereas patients with bronchiectasis, lung abscess, fungal disease, or a bleeding diathesis are more likely to have severe bleeding. 43 Less common conditions associated with hemoptysis include arteriovenous malformations, broncholithiasis, foreign bodies, aspergilloma, mitral stenosis, trauma, excessive anticoagulation, pulmonary hemorrhage syndromes, heart failure, pneumonia, and granulomatosis with polyangiitis (Wegener granulomatosis).

Prompt evaluation, beginning with a thorough history, is required in all patients. It is important to determine where the blood is coming from. Surprisingly, patients may not always be able to distinguish hemoptysis from hematemesis and nasopharyngeal bleeding. Vomiting blood may follow a prolonged coughing episode. Patients may swallow or aspirate blood from the upper airway. Some patients report only that the blood “welled up” in their throats. Others will say that it is mixed with sputum. Hematemesis can usually be differentiated from hemoptysis by the presence of symptoms of gastrointestinal involvement, such as nausea and vomiting, a history of peptic ulcer disease, alcoholism, or signs of cirrhosis; when in doubt, esophagoscopy is indicated.

Following physical examination, a chest radiograph and (often) a chest CT are required. Depending on the magnitude of the blood loss and the clinical circumstances, bronchoscopy is indicated to determine the location of the bleeding. Although these studies generally reveal which region of the lungs is the source, the cause of hemoptysis cannot be determined in 20% to 30% of cases. 46 Recent radiologic advances, which enhance identification of the culprit vessel, particularly multidetector computed tomographic angiography, have greatly helped the interventionalist when bronchial artery embolization is required to stop the bleeding. 47

Various types of chest pain are extremely common; their mechanisms and clinical patterns are described in Chapter 31. Chest pain is one of the most common symptoms that cause the sufferer to seek medical attention. Because there is no clear relationship between the intensity of the discomfort and the importance of its underlying cause, all complaints of chest pain must be carefully considered. The recent development of dedicated chest pain centers within emergency departments has improved the accuracy and rapidity of diagnosis, the treatment, and the survival of patients with this always troublesome symptom. 48

Pleurisy, or acute inflammation of the pleural surfaces, has several distinctive features. Pleuritic pain is usually localized and unilateral—and tends to be distributed along the intercostal nerve zones. Pain from diaphragmatic pleurisy is often referred to the ipsilateral shoulder and side of the neck. The most striking and defining characteristic of pleuritic pain is its clear relationship to respiratory movements. The pain may be variously described as “sharp,” “burning,” or simply “a catch,” but it is typically worsened by taking a deep breath, and coughing or sneezing causes intense distress. Patients with pleurisy frequently also experience dyspnea because the aggravation of their pain during inspiration makes them conscious of every breath.

Acute pleuritic pain is found in patients with spontaneous pneumothorax, pulmonary embolism, and pneumonia, especially pneumococcal pneumonia, whereas a gradual onset over several days is observed in patients with tuberculosis; an even slower development is characteristic of primary or secondary malignancies. Chronic pleuritic pain is characteristic of mesothelioma. It may be difficult to distinguish pleuritic pain from the pain of a rib fracture, although point localization favors the latter. Pericardial pain is typically sharp, retrosternal in location, and relieved by sitting up and leaning forward.

The distribution and the superficial, knifelike quality of the pain of intercostal neuritis or radiculitis may resemble pleural pain because it is worsened by vigorous respiratory movements but, unlike pleurisy, not by ordinary breathing. A neuritic origin may be suggested by the presence of lancinating or electric shock–like sensations unrelated to movements, and hyperalgesia or anesthesia over the distribution of the affected intercostal nerve provides confirmatory evidence. In many instances of new-onset, neuritic chest wall pain, the diagnosis becomes clear a day or two later when the typical vesicular rash of herpes zoster appears. 49

Among the most important types of chest pain is myocardial ischemia, which is usually caused by coronary artery atherosclerosis. These attacks, which are provoked by inadequate oxygen delivery to the myocardium, span a continuum of severity from chronic stable angina to classic acute myocardial infarction. Typical anginal pain is induced by exercise, heavy meals, and emotional upsets; the pain is usually described as a substernal “pressure,” “constriction,” or “squeezing” that, when intense, may radiate to the neck or down the ulnar aspect of one or both arms. 50 Pain from variant or Prinzmetal angina is similar in location and quality to typical anginal pain but is experienced intermittently at rest rather than during exertion. 51 Both typical and variant types of angina are relieved by coronary vasodilator drugs, such as nitroglycerin. Typical angina also decreases with rest or removal of the inciting stress.

By contrast, the pain of acute myocardial infarction, although similar in location and character to anginal pain, is usually of greater intensity and duration, is not alleviated by rest or by nitroglycerin, may require large doses of opiates, and is often accompanied by profuse sweating, nausea, hypotension, and arrhythmias. During attacks of myocardial ischemia and myocardial infarction, patients are often short of breath from associated pulmonary edema, which may be severe, but the pain itself is not related to breathing. Pain similar to that of myocardial ischemia also occurs in patients with aortic valve disease, especially aortic stenosis, and other noncoronary heart disease and extracardiac disorders.

Inflammation of or trauma to the joints, muscles, cartilages, bones, and fasciae of the thoracic cage is a common cause of chest pain. 52 Redness, swelling, and soreness of the costochondral junctions is called Tietze syndrome. All of these disorders are characterized by point tenderness over the affected area.

Most pulmonary thromboemboli are not associated with chest pain; the hallmark of pulmonary infarction, however, is typical pleuritic pain. Both acute and chronic causes of pulmonary hypertension may be associated with episodes of chest pain that resemble the pain of myocardial ischemia in its substernal location and pattern of radiation and in its being described as “crushing” or “constricting.” 52 This type of chest pain is believed to result from right ventricular ischemia owing to impaired coronary blood flow secondary to increased right ventricular mass and elevated systolic and diastolic pressures or to compression of the left main coronary artery by the dilated pulmonary artery trunk.

Family History and Social History

The family history provides important clues to the presence of heritable pulmonary diseases, such as cystic fibrosis, alpha 1 -antitrypsin deficiency, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), immotile cilia syndrome, and immunodeficiency syndromes, among others. Careful history taking also can uncover even more common familial disease associations, which are polygenic or in which the exact mode of genetic transmission has not yet been established. As genomic surveillance is uncovering more and more genetic linkages, the family history assumes an even more important function. The family history should encompass at least three generations to account for sex-linked traits. Family history also can identify exposures such as to tuberculosis or other contagious diseases.

Of course, no evaluation of pulmonary symptoms is complete without a detailed history of smoking habits. The physician should ask, “Have you ever smoked?” A negative answer should prompt a confirmatory response such as, “So you are a lifelong nonsmoker?” and a compliment if the second answer is yes. If the patient has smoked, the next questions should be, “When did you start?” “When did you quit?” and “How much did you smoke while you were at it?” Ask also about different forms of tobacco and exposure at home or workplace to other people's tobacco smoke. A history of exposure to environmental smoke is also important. 53 In many developing countries, smoke from indoor cooking and heating fires is a major cause of lung disease, especially in women. Risk factors for human immunodeficiency virus (HIV) infection, such as unprotected sexual activity and injection drug abuse, should be specifically queried.

Medications and Allergies

A complete list of all medications is essential to a thorough history. Ideally, the patient should bring in all his or her medications, and the physician should carefully go through each one, checking that the prescription has been properly written and filled and that the patient understands the benefit and possible side effects of each medicine. It is vital to note whether the patient has ever had an allergic or toxic reaction and what these reactions were. A complete listing of supplements and herbal medications should also be recorded and reviewed for potential interactions with conventional medications. No drug history is complete without assessing whether the patient drinks alcoholic beverages or uses illicit drugs. The amount and frequency of their use should be recorded.

Occupational History

The occupational history, which is often included as part of the social history, is an integral part of a thorough medical interview. Identifying a relevant occupational exposure may provide the only opportunity to remove the patient from the exposure and prevent progressive and irreversible lung damage. Moreover, identifying injurious occupational exposures can facilitate justifiable compensation for the patient and removal of the hazardous materials from the workplace by the industry.

The evaluation of suspected occupational lung disease is discussed in Chapters 64, 72, 73, and 74Chapter 64Chapter 72Chapter 73Chapter 74. Although only a few questions are asked in most initial medical interviews, if occupational illness is seriously being considered, a detailed inquiry about each industry, profession, and job the patient has held needs to be performed. 54 , 55 Because there are so many environmental agents and different associated illnesses, the diagnostician should consult online resources such as the National Institute for Occupational Safety and Health, the Environmental Protection Agency, Hazardous Substances Data Bank, the Occupational Safety and Health Administration, or other online resources to learn more about the putative environmental toxin. 56 , 57

Travel History

Previous places of residence help diagnose endemic fungal diseases, especially histoplasmosis and coccidioidomycosis. A history of recent travel may help establish the possibility of exposure to infectious diseases that are restricted to specific geographic regions. 58 The physician should inquire into the duration of travel. Long trips by air or car increase the risk for deep venous thrombosis and venous thromboembolism, which are reported in up to 10% of passengers on long-haul flights. 59 It is important to consider events after travel: symptoms of pulmonary thromboembolism and infarction may arise a variable time after the inciting event. The epidemic of severe acute respiratory syndrome (SARS) in southeast China in 2002 and its rapid spread throughout the world by airline passengers emphasizes the importance of obtaining a careful travel history.

Past Medical History

Previous illnesses may recur (e.g., tuberculosis), and new diseases may complicate old ones (e.g., bronchiectasis as a sequela of necrotizing pneumonia). Information about previous illnesses, operations, intubations, and trauma involving the respiratory system may be essential to understanding the current problem. Although these data may be gathered as part of the past medical history, much of the pertinent information will be absorbed into the chronological sequence of the history of present illness. Prior chest radiographs are an important aid in the evaluation of any abnormal chest radiograph because of the insights they provide into the duration and trajectory of illness. Patients should be asked to bring in previous films, but if they are unavailable, physicians should make every effort to obtain them, because old radiographs may save needless, costly, and sometimes risky interventions.

Information from Questionnaires and Other Sources

Printed or computer-based questionnaires and histories taken by nurses or allied health professionals are often used to expedite history taking. They can identify problems that can be explored further in the medical interview, and they facilitate a focused yet comprehensive evaluation. Occupational questionnaires have been shown to enhance recognition of occupational illness and correlate well with the findings of an industrial hygienist. 60 Computer-based interviews can gather more information, allow more time to complete the interview, uncover sensitive information, and may be adaptable to the hearing impaired and to persons speaking a language different from that of the physician. 61

These forms of information gathering should be considered adjuncts and not a substitute for the thorough history taken by the physician. The limitations of the programmed questions are that the patient may not understand or be able to express her or his concerns when confined by a form that does not allow the free exploration of symptoms that the open interview does. Automated data collection, of course, lacks the benefits gained from the patient-physician interaction, such as the establishment of rapport and the ability to observe nonverbal behavior. The interview itself also provides both time and opportunity for the physician to fully comprehend the patient's illness and to contemplate the primary and differential diagnoses.

For monitoring the course of certain disorders such as asthma, daily recording of symptoms, such as wheezing and breathlessness, and objective assessments of severity of disease, such as peak expiratory flow, in a diary are preferable to a single questionnaire because recall of symptoms may be faulty and one measurement may not be representative. The electronic monitoring that now comes as standard equipment with most home noninvasive ventilation devices gives the date and time of the respiratory events and the use of these devices.

Physical Examination

Sadly, the declining emphasis on proficiency in physical examination during medical school and residency training and the ever-increasing reliance on technology-based diagnosis have led to a decreased interest in, some say even the “demise” of, the physical examination. 62 However, the old observation that 88% of all diagnoses in primary care were established by taking a thorough medical history and performing a complete physical examination 63 probably still holds today. At the very least, a carefully executed history and physical lead to more intelligent and cost-effective use of diagnostic technology. Plus, a physical examination can be performed virtually anywhere, may provide important information, lends itself to serial observations, and increases patients' confidence in their physicians.

Examination of the Chest

Physical examination of the chest employs the four classic techniques of inspection, palpation, percussion, and auscultation. Each is described subsequently, as are the constellations of abnormalities that allow the examiner to infer the presence and type of various pulmonary disorders. Apart from inspection, which is not only a visual but also sometimes an olfactory tool and is always a structured cognitive skill, the other three modalities depend on the generation and the perception of sound or tactile sensations and vibrations. As was true of the history, the environment in which the physical examination takes place must be appropriate to the needs of both the examiner and the examined. Privacy, warmth, good light, and quiet are all essential. The best light source is natural sunlight, which should be used if possible. An ill-lit, noisy, or distracting environment will likely result in a physical examination that is flawed or incomplete.

The physical examination begins the moment the clinician first sees the patient, even before the introductions and beginning the medical interview. Keen observations, and the ability to pursue and interpret these observations, are the keys to skilled clinical diagnosis.

Inspection of the chest is carried out after sufficient clothing has been removed and the patient has been suitably draped to permit observation of the entire thorax. Ordinarily, inspection is performed with the patient sitting, but if the patient is too weak or cannot sit unaided, he or she should be supported in this position. Observing the shape and symmetry of the chest allows such abnormalities as kyphoscoliosis, pectus excavatum, pectus carinatum, ankylosing spondylitis, osteoporosis, gynecomastia, and surgical scars or defects to become obvious.

Several classic patterns of ventilation can be readily recognized ( Fig. 16-1 ). Examples are tachypnea, which is almost uniform rapid shallow breathing; Kussmaul breathing, which is relentless, rapid, and deep breathing (air hunger); Cheyne-Stokes respirations, a cyclical waxing and waning of the depth of breathing with regularly recurring periods of apnea; and Biot breathing, which is totally irregular breathing, both the size of breaths and the periods of apnea, which are sometimes prolonged. Impending respiratory failure from muscle fatigue can be detected by observing rapid shallow breathing, abdominal paradoxical motion, and alternation between rib cage and abdominal breathing, so-called respiratory alternans. 64 The Hoover sign is the paradoxical inward displacement of the costal margin at the end of inspiration or throughout inspiration. Decreased regional ventilation can be detected be seeing a lag in the motion of the affected part of the chest wall during breathing.

Schematic drawing of waveforms in different patterns of breathing.

Palpation of the thorax is a necessary part of the cardiac, breast, and lymph node examinations and often can detect bony abnormalities, such as a cervical rib, and subcutaneous calcinosis seen with systemic sclerosis. It is essential in examining causes of pain to determine point tenderness and thoracic spinal tenderness. It can detect fluctuant areas associated with empyema necessitans and crepitant areas associated with subcutaneous emphysema. Location by palpation of the trachea in the suprasternal notch is a useful way to detect shifts of the mediastinum. A spastic, extrafirm-feeling back muscle recognized by palpation may identify the cause of thoracic pain. A lag in movement of the chest wall, suspected from inspection, can be confirmed by placing the two hands over opposite portions of each hemithorax and both feeling and observing whether or not the thorax moves symmetrically. 65 Symmetry is as important in palpation as it is in inspection.

A palpable vibration felt on the body, usually over the chest, is called fremitus. Vocal fremitus is elicited by having the patient speak “one, two, three,” while the examiner's two palms or sides of the hands are moved horizontally from top to bottom of the two hemithoraces. Vocal fremitus is increased over regions of lungs through which there is increased transmission of sound, for example, consolidation from pneumonia. Conversely, fremitus is decreased in conditions in which sound transmission is impaired, for example, pleural effusion. Occasionally, fremitus over part of the chest wall can detect the presence of airway secretions (rhonchal fremitus) or an underlying pleural friction rub (friction fremitus).

In examining the heart the examining physician should always search for an apical impulse, heaves and lifts, thrills, and palpable valve closure. In patients with severe COPD, abnormal cardiac movements are often better felt in the subxiphoid region than over the precordium.

Skillful percussion depends on a uniform free and easy stroke of the striking finger (plexor) on the finger being struck (pleximeter), the ability to sense minor changes in pitch, and a keen sense of vibration—although the percussion note is heard, it is predominantly felt. Percussion of the thorax over normal air-containing lung produces a resonant note.

Sounds and tactile perception from percussion vary depending on the thickness of the skin, subcutaneous layer, breast tissue, and chest wall, as well as on the quality, distribution, and tension of the air under the area percussed. Pathologic processes may impair or enhance the resonating quality of the thorax. For example, the percussion note over a large pneumothorax is hyperresonant and becomes tympanitic when tension is present; in contrast, percussion over a pleural effusion or pneumonia produces dullness, which has been defined as a low-intensity sound of short duration, feeble carrying power, and rather high pitch. 66 Flatness is the unresonating sound obtained by percussing over the liver. Three different tonal zones can thus be detected when percussing large pleural effusions: normal resonance above the fluid, dullness in the middle, and flatness when completely below the fluid; these variations in sound may result from the presence of an internal meniscus or fluid wedge, which points upward into the lung above it. Carrying out a thoracentesis in the dull area offers the best chance of obtaining pleural fluid and avoids puncturing either an abdominal viscus or air-containing lung.

Auscultation

A stethoscope draped around the neck has long been the badge of the medical professional, and it is worn with pride by physicians, nurses, and respiratory therapists, despite predictions such as “it, too, will someday be relegated to a museum shelf.” 67 This will not happen for a long time, according to Murphy, 68 who mounts a spirited defense of stethoscopes backed up by analyses of breath sounds obtained by respiratory acoustic recording. Indeed, there is now a body of literature on computer-assisted mapping of breath sounds using both recording and imaging techniques which provides new insights into their origin and clinical significance. 69 , 70 , 71 For example, computerized multisensor breath sound imaging has proved to be a sensitive and specific tool for differentiating pneumonia or pleural effusion from normal lungs. 72 Similarly, signal analysis of heart sounds recorded by digital electronic means has promising clinical applications and is useful for teaching cardiac auscultation. 73 The fundamentals of lung auscultation in physical examination have been reviewed recently. 74

Stethoscopes are also helpful in picking up wheezes in asthmatics and crackles in patients with interstitial lung disease whose chest radiograph findings are normal. Moreover, patients expect their physicians to listen to their hearts and lungs if they have cardiorespiratory complaints.

Like any piece of medical equipment, there are a number of available choices, and the design and care of the stethoscope may have a substantial impact on its performance. Electronic models promise ambient noise reduction and audio amplification, features that have been shown in randomized trials to provide statistically significant improvements in acoustics, especially in noisy environments. 75 , 76 However, the magnitude of improvement is small relative to the best acoustic stethoscopes, and electronic stethoscopes have not been shown to improve trainee performance. 77 Sound quality with any stethoscope can be substantially degraded by failure to maintain the integrity of the rubber fittings, and prolonged contact of the tubing with the skin when worn around the neck can lead to hardening of the tubing and decreased performance. In any case, the stethoscope must be kept clean because it is increasingly recognized as a vector of nosocomial infection. 78

The terminology of breath sounds has been standardized and simplified to enhance understanding and communication ( Table 16-2 ). Although a standardized nomenclature has been proposed by the American Thoracic Society 79 and the Tenth International Conference on Lung Sounds, 80 communication at the bedside often strays from recommended terminology.

Classification of Common Lung Sounds

The basic technique of auscultation with an ordinary stethoscope is well known to most physicians: the diaphragm detects higher-pitched sounds, and the bell detects lower-pitched sounds, although if the bell is tightly pressed against the body, the taut underlying skin itself may serve as a “diaphragm” and improve perception of higher pitches. Conversely, the bell should be applied very lightly to hear, for example, the low-pitched rumble of mitral stenosis. Full contact with the skin is necessary for best listening, which may pose a problem in a patient whose intercostal spaces are sunken from weight loss. In addition, the skin or hairs may brush against the diaphragm and produce a sound that resembles a pleural friction rub. As with examiners' hands, a warm stethoscope head is appreciated by patients. The importance of a quiet room and of applying the stethoscope directly to the skin rather than through clothing has recently been reemphasized. 81 At times, especially in the intensive care unit, it is not always possible to sit patients up to listen carefully to their backs, which compromises the completeness of auscultation.

This chapter includes links to audio recordings, some with animations. To hear the recorded lung sounds at their intended pitch and intensity, it is recommended that readers listen through a stethoscope, with the chest piece held 4–5 inches from the audio speaker.

Interposition of a sound barrier between the central airways where sounds originate and the chest wall where they are heard also attenuates or interrupts transmission of normal lung sounds. Accordingly, normal breath sounds are diminished or absent over a pleural effusion, pneumothorax, and peripheral bullae, or distal to an obstructing mass lesion. Conversely, they may be increased if chest wall deformity or bronchial or tracheal derangement allows movement of air to be closer than usual to the stethoscope.

Adventitious Sounds

The major types of adventitious sounds are classified in Table 16-2 . Two generic categories of adventitious sounds have been documented by high-speed recording techniques, and each of these has two subdivisions: discontinuous sounds, including fine crackles and coarse crackles, and continuous sounds, including wheezes and rhonchi. 83

Discontinuous Sounds (Crackles)

The timing of crackles is also important. Nath and Capel 85 have shown that late-inspiratory crackles are more often found in restrictive than obstructive lung disease. In a study by Pürilä and colleagues, 86 the crackles of pulmonary fibrosis began at 45% of inspiration, whereas those of nonfibrotic lung conditions were heard earlier: COPD at 25%, bronchiectasis at 33%, and heart failure at 37% of inspiration. 86 This suggests that more tension is required to open individual airways in fibrosis than in lungs with secretions or edema. As inspiration progresses, radial traction on airway walls increase until suddenly they pop open. 85 Thus crackles heard later in inspiratory time imply that the tension required to open individual airways is greater. Coughing or deep inspiration may change the quality of coarse crackles, such as those associated with underlying alveolar or airway disease, but the crackles rarely disappear entirely. Expiratory crackles are much less frequent than inspiratory crackles and are often seen in obstructive lung disease. 83

Continuous Sounds (Wheezes)

Voice-generated sounds, pleural friction rub, extrapulmonary sounds.

The presence of air or other gas in the mediastinum may be associated with crunching, crackling sounds that are synchronous with cardiac contraction and are audible when breathing is momentarily stopped. The finding of a mediastinal crunch by auscultation usually signifies mediastinal emphysema, even when the chest radiograph shows no abnormalities. In contrast, a pleural friction rub is usually heard during both inspiration and expiration and has a higher pitch.

Interpretation

When abnormalities are discovered on physical examination of the chest, it is useful to identify them by their anatomic location in the involved lung. This requires knowledge of the surface projections of the underlying bronchopulmonary lobes, which are shown in Figure 16-2 . The upper and lower lobes of both lungs are separated by the two oblique fissures, which course from the spinous process of the third thoracic vertebra posteriorly to the level of the 6th rib in the midclavicular line anteriorly. On the right side anteriorly, the upper and middle lobes are separated by the horizontal fissure, which lies at about the level of the fourth costal cartilage. In the presence of either distortions of pulmonary anatomy or the shape of the rib cage, the surface projections of the underlying lung also change.

Schematic drawing shows surface projections of underlying lobar anatomy of a healthy man.

Ling, lingular division of left upper lobe; LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe.

The classic findings on physical examination of the chest in some common pulmonary disorders are shown in Table 16-3 . Ordinarily, consolidation must be within 1 or 2 cm of the costal surface to be reliably detected. Even then, physical examination alone cannot be relied upon to diagnose or exclude pneumonia. 91 Some pneumonias, such as Mycoplasma pneumonia, typically cause surprisingly few physical abnormalities despite extensive radiographic involvement (see eFig. 33-9) but, even in patients with classic lobar pneumonia, the findings may be nonspecific. Although unable to distinguish reliably between new-onset pneumonia and other pulmonary diseases, the findings from physical examination—vital signs, mental confusion, cyanosis, use of accessory muscles, and paradoxical breathing—are extremely important in assessing severity and in deciding whether or not to hospitalize patients with pneumonia. 92

Classic Physical Findings in Some Common Pulmonary Disorders

The distinction between pleural effusion and atelectasis can be made on physical examination by determining whether the heart and mediastinal contents shift toward or away from the abnormal side, a finding that can usually be made only if the effusion is large or the atelectasis involves at least one lobe. When these full-blown manifestations are present, the presence of the causative disorder can be inferred with reasonable certainty. However, the absence of these findings does not exclude an abnormality, and a chest radiograph must always be taken as part of the complete pulmonary workup.

Extrapulmonary Manifestations

The examination of the lungs and pleura unlock only some of the clues to the presence of lung disease. Looking for extrapulmonary signs can often point toward a specific pulmonary disease or toward systemic diseases such as lupus erythematosus or toward diseases arising elsewhere in the body that secondarily involve the lung. Certain extrapulmonary manifestations are particularly useful.

The association of clubbing of the fingers or toes with disease has caught the attention of physicians since the time of Hippocrates. Clubbing is easy to recognize when it is severe ( Fig. 16-3 ), but subtle changes are more common and less reliable. The hallmarks of clubbing are (1) a softening and periungual erythema of the nail beds, which causes the nails to seem to float rather than to be firmly attached, (2) an increase of the normal 165-degree angle that the nail makes with its cuticle, (3) an enlargement or bulging of the distal phalanx, which may be warm and erythematous, and (4) a curvature of the nails themselves. Of these features, the straightening of the nail cuticle angle appears to be the most sensitive measurement. 93

Clubbing of the digits as seen in severe diffuse interstitial pulmonary fibrosis.

Patients with clubbing may also have hypertrophic osteoarthropathy, a condition characterized by subperiosteal formation of new cancellous bone at the distal ends of long bones, especially the radius and ulna and the tibia and fibula. Hypertrophic osteoarthropathy ( Fig. 16-4 ) is almost always associated with clubbing, particularly in patients with bronchogenic carcinoma, other intrathoracic malignancies, and cystic fibrosis. It occasionally develops in patients with bronchiectasis, empyema, and lung abscess but is rare in patients with most of the other conditions in which clubbing has been observed. 94 One of the striking features of clubbing is the speed with which it can develop, about 2 weeks in patients with new-onset empyema, and with which it can reverse, also about 2 weeks in patients after corrective cardiac surgery. The presence of clubbing, which was found in 1% of all admissions to an internal medicine department, was associated with “serious disease” in 40% of afflicted patients 95 ; therefore new-onset clubbing always warrants a chest radiograph, and if no abnormality is found, a CT scan to look for a pulmonary neoplasm or other lesion, which may still be localized and curable.

Radiographs of the leg show marked subperiosteal new bone formation ( arrows ) that is diagnostic of hypertrophic osteoarthropathy.

A, Most of tibia and fibula. B, Detailed view near the ankle.

Clubbing has been found in many diverse conditions, such as children with HIV, 96 hepatopulmonary syndrome, 97 and benign asbestos pleural disease 98 ( Table 16-4 ). Both clubbing and hypertrophic osteoarthropathy can be idiopathic or familial; the familial form is often transmitted as a dominant trait. The hereditary form of hypertrophic osteoarthropathy is also called pachydermoperiostosis, a condition in which bone and joint involvement is often mild but furrowing of the skin of the face and scalp is usually marked.

Causes of Clubbing (Partial Listing)

AV, arteriovenous.

The main pathologic finding in clubbing is increased capillary density. The most potent stimulus to new capillary growth is hypoxia, which causes an intense production of vascular growth factors, such as vascular endothelial growth factor. With histochemical staining, Atkinson and Fox 99 showed increases in vascular endothelial growth factor, platelet-derived growth factor, hypoxia-inducible factor-1α, and hypoxia-inducible factor-2α along with increased microvessel density in the stroma of clubbed digits. The second common characteristic of patients with digital clubbing is shunting of blood past the capillary bed of either the lung or the liver, which suggests that lack of metabolism of angiogenic factors that bypass a critical organ may be involved. Several of the conditions associated with clubbing have inflammation and shunting, such as bronchiectasis and liver cirrhosis.

Other Extrapulmonary Associations

Besides clubbing, thoracic neoplasms may cause other extrathoracic abnormalities that may become evident on physical examination, including anemia, Cushing syndrome, gynecomastia, and other paraneoplastic syndromes ( Table 16-5 ). Other common extrathoracic manifestations that provide clues to the presence or state of an underlying malignancy are wasting, hoarseness, adenopathy (especially supraclavicular), and hepatomegaly. When evaluating patients with dyspnea, a thorough examination of the neck veins for evidence of increased central venous pressure and careful cardiac auscultation for the presence of a third heart sound or distinctive murmurs should be performed to exclude heart failure. 100 The extremities should also be examined for evidence of peripheral edema, venous thrombosis, chronic venous stasis, and scars that suggest injection drug abuse.

Paraneoplastic Syndromes (Partial Listing)

ACTH, adrenocorticotropic hormone.

The association of abnormalities in other organ systems with underlying lung disease can be very helpful in making a diagnosis.

A wide variety of cutaneous or subcutaneous lesions ( eTable 16-1 ) 99 and ocular lesions ( eTable 16-2 ) 100 has been associated with various primary lung disorders. Likewise, a combination of lung and kidney disease ( eTable 16-3 ); lung and bone, joint, muscle, or nerve lesions ( eTable 16-4 ); and gastrointestinal and hepatic involvement ( eTable 16-5 ) may suggest a unifying disease process that can be detected by physical examination.

eTable 16-1

Skin and Subcutaneous Lesions Associated with Lung Disease

eTable 16-2

Eye Involvement in Lung Disease

eTable 16-3

Renal Involvement in Lung Disease

eTable 16-4

Joint, Bone, Muscle, and Neurologic Involvement in Lung Disease

eTable 16-5

Gastrointestinal and Hepatic Involvement in Lung Disease

• ▪ Taking a careful history and performing a thorough physical examination are essential first steps in formulating a preliminary differential diagnosis of a patient's complaints.
• ▪ After the clinician arrives at a tentative diagnosis, selected radiographic, laboratory, and other tests are ordered for further and confirmatory evaluation.
• ▪ The electronic medical record provides documents of higher quality than written records, owing to improved organization, increased readability, use of supplementary material, and better comparisons.
• ▪ Because dyspnea, cough with or without hemoptysis, and chest pain are among the most common reasons for patients to visit physicians and because these symptoms may result from serious underlying chest disease, careful questioning and workup is mandatory.
• ▪ Physical examination can be performed virtually anywhere, provides important information, lends itself to serial observations, and increases patients' confidence in their physicians.
• ▪ Stridor, a high-pitched continuous sound which, in contrast to wheezing, is louder and longer during inspiration than expiration, can indicate a life-threatening upper airway obstruction and requires immediate attention.
• ▪ New-onset clubbing of the digits warrants detection and investigation owing to its frequent association with serious underlying disease.

Complete reference list available at ExpertConsult.

Key Readings

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• McGee SR. ed 3. Elsevier/Saunders; Philadelphia: 2012. Evidence-based physical diagnosis. [ Google Scholar ]

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2.10: Sample Documentation

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Information obtained during a health history interview is typically documented on agency-specific forms. See “ Chapter Resources A ” for a sample health history form used for documentation purposes. Additional information collected that is not included on the form should be documented in an associated progress note.

• EXPLORE Random Article

How to Summarize Your Own Medical History

Last Updated: January 6, 2024 References

wikiHow is a “wiki,” similar to Wikipedia, which means that many of our articles are co-written by multiple authors. To create this article, 25 people, some anonymous, worked to edit and improve it over time. This article has been viewed 130,672 times.

Medical schools teach that the most important step of making an accurate medical diagnosis is not the physical examination or expensive medical tests and equipment. The doctor is best served by taking a complete patient history. Surprisingly, most people do not know or remember many of the details of their own health. This is a frustration to all health professionals, and can contribute to a misdiagnosis and medical errors. Technology will eventually catch up with our need to have timely access to medical information. In the meantime, follow these steps to create a quick record of your past medical history.

• Date of birth
• Health insurance information (provider, policy number)
• Next of kin and/or Power of Attorney for Care
• Addresses and phone numbers
• Name and phone number of primary care provider
• Name and phone number of pharmacy

• All known medical diagnoses, past and present
• All surgeries, with name of surgery, date, and outcome
• Allergies, especially to medications, and what reaction you had [1] X Trustworthy Source National Health Service (UK) Public healthcare system of the UK Go to source
• Names, specialties, and phone numbers of any physicians who are still following you
• List significant diagnoses or severe illnesses of close family members, such as parents and siblings. [2] X Research source

• Prescription medications including dose and number of times per day taken.
• Specialized treatments such as chemotherapy, drug trials, medication injections
• Over-the-counter medications, i.e., Tylenol, Gravol
• Herbal remedies, vitamins and supplements
• Cigarettes per day
• Alcohol consumption per day (average), week, or month
• Recreational drugs, if any (marijuana, cocaine, etc.)

• Most recent sets of blood work (if there has been a significant change, include the older set too)
• Written report of x-rays and scans [4] X Trustworthy Source National Health Service (UK) Public healthcare system of the UK Go to source (there is no need to bring the actual films or CD unless seeing a specialist in that field)
• If you have ever had any cardiac issues, a photocopy of your most recent electrocardiogram (ECG). This is very important, as most cardiac care is time-dependent.
• 6 If it applies to you, include the number of times you've been pregnant. This is especially important if you are currently pregnant or undergoing fertility treatment. Be detailed with this information. Include all pregnancies, the duration and the outcome. It may be upsetting to write clinically about a still birth or miscarriage but this information might be important to your health care and the outcomes of any current or future pregnancies.

• Full Code - If you are unable to say otherwise, all medical measures will be taken, including life support.
• DNR - "Do Not Resuscitate"
• No CPR, no ventilation, no life support
• No blood transfusions
• Organ donation authorized

Expert Q&A

• Carry a copy of it with you everywhere, in the same place you keep your health card. Thanks Helpful 0 Not Helpful 0
• If you are on many prescription medications, your pharmacy may be able to print out a summary. Thanks Helpful 0 Not Helpful 0
• Whenever registering for an appointment or visiting the emergency room, show the sheet to the first nurse who assesses you and ask that it be shown to the doctor. Also, be sure to show the sheet to an emergency medical technician (EMT) or paramedic should an ambulance be called for you. Thanks Helpful 0 Not Helpful 0
• Don't assume that technology will make your job as a patient easier. People are on a larger variety of more complicated treatments. They are living longer with diseases that used to be fatal. There is a greater (and unmet) expectation on the part of the public that, somehow, all their medical information is available by computer and shared between all relevant parties. Up to now, this is NOT the case. Even in a modern hospital emergency department, where the most acute care is provided, many patients are treated even when there is no access to any previous health records. Thanks Helpful 3 Not Helpful 1
• This CPP serves the same purpose as a cover letter in a job interview. It's best kept to a single page; if it takes longer to read than it does to hunt for the information in other ways, the doctor may not be able to give it the time it deserves. Thanks Helpful 3 Not Helpful 1
• Do not omit or falsify any information. Your life may depend on the accuracy of your summary, particularly if you come to the hospital in a critical state and cannot speak for yourself. Thanks Helpful 4 Not Helpful 2

You Might Also Like

• ↑ https://www.nhs.uk/using-the-nhs/about-the-nhs/your-health-records/
• ↑ https://www.webmd.com/a-to-z-guides/what-is-my-medical-history
• ↑ https://www.uncpn.com/app/files/public/664e1f36-c9bf-4f5f-a03d-93f7ced2b564/uncpn-form-new-patient-medical-history.pdf
• Wikipedia entry on "Personal Health Record"
• Wikipedia entry on "Do Not Resuscitate"
• Wikipedia entry on "Medical identification tag "

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Steps for Writing a History Paper

Writing a history paper is a process.  Successful papers are not completed in a single moment of genius or inspiration, but are developed over a series of steps.  When you first read a paper prompt, you might feel overwhelmed or intimidated.  If you think of writing as a process and break it down into smaller steps, you will find that paper-writing is manageable, less daunting, and even enjoyable.  Writing a history paper is your opportunity to do the real work of historians, to roll up your sleeves and dig deep into the past.

What is a History paper?

History papers are driven by arguments.  In a history class, even if you are not writing a paper based on outside research, you are still writing a paper that requires some form of argument.  For example, suppose your professor has asked you to write a paper discussing the differences between colonial New England and colonial Virginia.  It might seem like this paper is straightforward and does not require an argument, that it is simply a matter of finding the “right answer.”  However, even here you need to construct a paper guided by a larger argument.  You might argue that the main differences between colonial New England and Virginia were grounded in contrasting visions of colonization.  Or you might argue that the differences resulted from accidents of geography or from extant alliances between regional Indian groups.  Or you might make an argument that draws on all of these factors.  Regardless, when you make these types of assertions, you are making an argument that requires historical evidence.  Any history paper you write will be driven by an argument demanding evidence from sources.

History writing assignments can vary widely–and you should always follow your professor’s specific instructions–but the following steps are designed to help no matter what kind of history paper you are writing.  Remember that the staff of the History Writing Center is here to assist you at any stage of the writing process.

• Sometimes professors distribute prompts with several sub-questions surrounding the main question they want you to write about.  The sub-questions are designed to help you think about the topic.  They offer ideas you might consider, but they are not, usually, the key question or questions you need to answer in your paper.  Make sure you distinguish the key questions from the sub-questions.  Otherwise, your paper may sound like a laundry list of short-answer essays rather than a cohesive argument. A helpful way to hone in on the key question is to look for action verbs, such as “analyze” or “investigate” or “formulate.”  Find such words in the paper prompt and circle them.  Then, carefully consider what you are being asked to do.  Write out the key question at the top of your draft and return to it often, using it to guide you in the writing process.  Also, be sure that you are responding to every part of the prompt.  Prompts will often have several questions you need to address in your paper.  If you do not cover all aspects, then you are not responding fully to the assignment.  For more information, visit our section, “Understanding Paper Prompts.”
• Before you even start researching or drafting, take a few minutes to consider what you already know about the topic.  Make a list of ideas or draw a cluster diagram, using circles and arrows to connect ideas–whatever method works for you.  At this point in the process, it is helpful to write down all of your ideas without stopping to judge or analyze each one in depth.  You want to think big and bring in everything you know or suspect about the topic.  After you have finished, read over what you have created.  Look for patterns or trends or questions that keep coming up.  Based on what you have brainstormed, what do you still need to learn about the topic?  Do you have a tentative argument or response to the paper prompt?  Use this information to guide you as you start your research and develop a thesis.
• Depending on the paper prompt, you may be required to do outside research or you may be using only the readings you have done in class.  Either way, start by rereading the relevant materials from class.  Find the parts from the textbook, from the primary source readings, and from your notes that relate to the prompt. If you need to do outside research, the UCLA library system offers plenty of resources.  You can begin by plugging key words into the online library catalog.  This process will likely involve some trial and error.  You will want to use search terms that are specific enough to address your topic without being so narrow that you get no results.  If your keywords are too general, you may receive thousands of results and feel overwhelmed.  To help you narrow your search, go back to the key questions in the essay prompt that you wrote down in Step 1.  Think about which terms would help you respond to the prompt.  Also, look at the language your professor used in the prompt.  You might be able to use some of those same words as search terms. Notice that the library website has different databases you can search depending on what type of material you need (such as scholarly articles, newspapers, books) and what subject and time period you are researching (such as eighteenth-century England or ancient Rome).  Searching the database most relevant to your topic will yield the best results.  Visit the library’s History Research Guide for tips on the research process and on using library resources.  You can also schedule an appointment with a librarian to talk specifically about your research project.  Or, make an appointment with staff at the History Writing Center for research help.  Visit our section about using electronic resources as well.
• By this point, you know what the prompt is asking, you have brainstormed possible responses, and you have done some research.  Now you need to step back, look at the material you have, and develop your argument.  Based on the reading and research you have done, how might you answer the question(s) in the prompt?  What arguments do your sources allow you to make?  Draft a thesis statement in which you clearly and succinctly make an argument that addresses the prompt. If you find writing a thesis daunting, remember that whatever you draft now is not set in stone.  Your thesis will change.  As you do more research, reread your sources, and write your paper, you will learn more about the topic and your argument.  For now, produce a “working thesis,” meaning, a thesis that represents your thinking up to this point.  Remember it will almost certainly change as you move through the writing process.  For more information, visit our section about thesis statements.  Once you have a thesis, you may find that you need to do more research targeted to your specific argument.  Revisit some of the tips from Step 3.
• Now that you have a working thesis, look back over your sources and identify which ones are most critical to you–the ones you will be grappling with most directly in order to make your argument.  Then, annotate them.  Annotating sources means writing a paragraph that summarizes the main idea of the source as well as shows how you will use the source in your paper.  Think about what the source does for you.  Does it provide evidence in support of your argument?  Does it offer a counterpoint that you can then refute, based on your research?  Does it provide critical historical background that you need in order to make a point?  For more information about annotating sources, visit our section on annotated bibliographies. While it might seem like this step creates more work for you by having to do more writing, it in fact serves two critical purposes: it helps you refine your working thesis by distilling exactly what your sources are saying, and it helps smooth your writing process.  Having dissected your sources and articulated your ideas about them, you can more easily draw upon them when constructing your paper.  Even if you do not have to do outside research and are limited to working with the readings you have done in class, annotating sources is still very useful.  Write down exactly how a particular section in the textbook or in a primary source reader will contribute to your paper.
• An outline is helpful in giving you a sense of the overall structure of your paper and how best to organize your ideas.  You need to decide how to arrange your argument in a way that will make the most sense to your reader.  Perhaps you decide that your argument is most clear when presented chronologically, or perhaps you find that it works best with a thematic approach.  There is no one right way to organize a history paper; it depends entirely on the prompt, on your sources, and on what you think would be most clear to someone reading it. An effective outline includes the following components: the research question from the prompt (that you wrote down in Step 1), your working thesis, the main idea of each body paragraph, and the evidence (from both primary and secondary sources) you will use to support each body paragraph.  Be as detailed as you can when putting together your outline.

If you have trouble getting started or are feeling overwhelmed, try free writing.  Free writing is a low-stakes writing exercise to help you get past the blank page.  Set a timer for five or ten minutes and write down everything you know about your paper: your argument, your sources, counterarguments, everything.  Do not edit or judge what you are writing as you write; just keep writing until the timer goes off.  You may be surprised to find out how much you knew about your topic.  Of course, this writing will not be polished, so do not be tempted to leave it as it is.  Remember that this draft is your first one, and you will be revising it.

A particularly helpful exercise for global-level revision is to make a reverse outline, which will help you look at your paper as a whole and strengthen the way you have organized and substantiated your argument.  Print out your draft and number each of the paragraphs.  Then, on a separate piece of paper, write down each paragraph number and, next to it, summarize in a phrase or a sentence the main idea of that paragraph.  As you produce this list, notice if any paragraphs attempt to make more than one point: mark those for revision.  Once you have compiled the list, read it over carefully.  Study the order in which you have sequenced your ideas.  Notice if there are ideas that seem out of order or repetitive.  Look for any gaps in your logic.  Does the argument flow and make sense?

When revising at the local level, check that you are using strong topic sentences and transitions, that you have adequately integrated and analyzed quotations, and that your paper is free from grammar and spelling errors that might distract the reader or even impede your ability to communicate your point.  One helpful exercise for revising on the local level is to read your paper out loud.  Hearing your paper will help you catch grammatical errors and awkward sentences.

Here is a checklist of questions to ask yourself while revising on both the global and local levels:

– Does my thesis clearly state my argument and its significance?

– Does the main argument in each body paragraph support my thesis?

– Do I have enough evidence within each body paragraph to make my point?

– Have I properly introduced, analyzed, and cited every quotation I use?

– Do my topic sentences effectively introduce the main point of each paragraph?

– Do I have transitions between paragraphs?

– Is my paper free of grammar and spelling errors?

• Congratulate yourself. You have written a history paper!

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How to Write a Health History

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Academic level: College

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In this report, I interviewed my mother primarily because most of my friends were not willing to give genuine answers. Besides, I felt that it would be easy to interview my mother since we are very close friends and I know her more than anybody else as I have been living with her from the time I was born. Presently, she is experiencing occasional back and joint pains, fatigue, increased sweating and breathlessness. Based on her past health, she has had several illnesses including cold and flu, allergies, depression, and overweight issues. She also underwent surgery for the treatment of fibroids. Looking at her family medical history, her father suffered from a stroke and high blood pressure. Moreover, her mother and one of her sister has diabetes. Her mother was also diagnosed with overweight issues and is currently struggling to overcome the condition. 

Conducting the interview was not an easy task, and thus, I had to employ certain approaches to encourage her to cooperate and give out reliable information. First, I asked her open-ended questions. Using such questions aids in understanding the client's opinions and arouses their feelings on a particular situation or topic. Open-ended questions also motivate the interviewee to do most of the talking and spur the direction of the conversation. Secondly, I ensured that I listened to her emphatically. By so doing, I encouraged a non-judgmental and collaborative relationship with her. Thirdly, I avoided engaging in an argument and confrontation with her. Ideally, arguments usually cause certain clients to take opposite sides and may degenerate to power struggles. Fourthly, I embraced self-efficacy and optimism throughout the interview. In doing this, I offered to her certain possible treatment options for her current condition. 

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Furthermore, I highlighted to her some examples of people who had similar medical issues and how they managed to overcome them. Finally, I capitalized in adjusting to her resistance to particular subjects of the interview rather than opposing them directly. Resistance is helpful as it allows the interviewer to respond in a lucrative way and taking the advantage of the process without being argumentative. 

Despite the successful accomplishment of the interview, there were some challenges, especially when asking about the health history of her family. Her father died a few years ago because of stroke and high blood pressure. Therefore, I knew that by asking questions relating to family medical history would remind her of such painful incidence. However, In order to help her answer my questions appropriately, I employed empathy by offering inspiring comments without building an emotional connection. Besides, I maintained a humorous outlook to help in lightening my mood when listening to her painful story about her father and the prevailing condition of her mother and sister. I also ensured a professional attitude in order to uncover the source of her resistance and give her a chance to acknowledge her feelings. Moreover, it helped me to avoid being defensive by taking deep breaths to calm myself. 

Taking health history was an enjoyable test and offered a great experience to me. Based on the various techniques I have learned in class, I was confident in the whole interview, and I was ready to overcome any potential challenges related to the investigation. In the past, I have also gone through several appointments with professional doctors, and thus, this empowered me to conduct the study without many difficulties. Many people face challenges primarily because of a lack of cooperation from the clients and the inability to control emotions. However, since I was interviewing my mother, I had a high sense of self-confidence, and it was easy to gain useful information without much resistance. Helping her to relax in particular situations was also easy. 

During the interview, I employed various interviewing approaches including active listening, adaptive questioning, non-verbal communication, Empathy, validation, and reassurance, and partnership and summarization. Although I used the above-interviewing styles effectively, I had difficulties in coping with some of them. Listening actively to someone without making defenses or being confrontational is an uphill task. Nevertheless, I kept continuous eye contact with her and complete concentration through the assessment. Furthermore, I encouraged her using both verbal and non-verbal prompts to help her in expanding on her current symptoms. Adaptive questioning also posed a challenge to me since my mother detests questions. In dealing with that situation, I began with general questions and further making them more precise through the interview. I also asked for additional information by requesting her to clarify particular issues in her statements. Since summarizing of essential points is imperative in interviewing a client, I had difficulties in balancing the interview and noting down the most lucrative elements. Nonetheless, I overcame that by requesting for repeat explanation of certain points to aid in easy recalling even after the assessment. 

After summarizing the crucial elements of health history, medical practitioners understand two main issues, which include the viewpoint of the client about their current conditions and how they say it. The things that the client highlights act as the factual content for a physical to use as the medical history and he usually edits and records as medical history. The doctor will thus use the information such as that of the family history to conduct tests mainly related to a particular disease in the family lineage. Besides, the medical assistant will revisit the information on the past illness and current symptoms to ascertain the possible disease of that particular client. 

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FACT SHEET: President   Biden Issues Executive Order and Announces New Actions to Advance Women’s Health Research and   Innovation

In his State of the Union address, President Biden laid out his vision for transforming women’s health research and improving women’s lives all across America. The President called on Congress to make a bold, transformative investment of $12 billion in new funding for women’s health research. This investment would be used to create a Fund for Women’s Health Research at the National Institutes of Health (NIH) to advance a cutting-edge, interdisciplinary research agenda and to establish a new nationwide network of research centers of excellence and innovation in women’s health—which would serve as a national gold standard for women’s health research across the lifespan.

It is long past time to ensure women get the answers they need when it comes to their health—from cardiovascular disease to autoimmune diseases to menopause-related conditions. To pioneer the next generation of discoveries, the President and the First Lady launched the first-ever White House Initiative on Women’s Health Research , which aims to fundamentally change how we approach and fund women’s health research in the United States.

Today, President Biden is signing a new Executive Order that will direct the most comprehensive set of executive actions ever taken to expand and improve research on women’s health. These directives will ensure women’s health is integrated and prioritized across the federal research portfolio and budget, and will galvanize new research on a wide range of topics, including women’s midlife health.

The President and First Lady are also announcing more than twenty new actions and commitments by federal agencies, including through the U.S. Department of Health and Human Services (HHS), the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the National Science Foundation (NSF). This includes the launch of a new NIH-wide effort that will direct key investments of $200 million in Fiscal Year 2025 to fund new, interdisciplinary women’s health research—a first step towards the transformative central Fund on Women’s Health that the President has called on Congress to invest in. These actions also build on the First Lady’s announcement last month of the Advanced Research Projects Agency for Health (ARPA-H) Sprint for Women’s Health , which committed $100 million towards transformative research and development in women’s health.

Today, the President is issuing an Executive Order that will:

• Integrate Women’s Health Across the Federal Research Portfolio . The Executive Order directs the Initiative’s constituent agencies to develop and strengthen research and data standards on women’s health across all relevant research and funding opportunities, with the goal of helping ensure that the Administration is better leveraging every dollar of federal funding for health research to improve women’s health. These actions will build on the NIH’s current policy to ensure that research it funds considers women’s health in the development of study design and in data collection and analysis. Agencies will take action to ensure women’s health is being considered at every step in the research process—from the applications that prospective grantees submit to the way that they report on grant implementation.
• Prioritize Investments in Women’s Health Research . The Executive Order directs the Initiative’s constituent agencies to prioritize funding for women’s health research and encourage innovation in women’s health, including through ARPA-H and multi-agency initiatives such as the Small Business Innovation Research Program and the Small Business Technology Transfer Program. These entities are dedicated to high-impact research and innovation, including through the support of early-stage small businesses and entrepreneurs engaged in research and innovation. The Executive Order further directs HHS and NSF to study ways to leverage artificial intelligence to advance women’s health research. These additional investments—across a wide range of agencies—will support innovation and open new doors to breakthroughs in women’s health.
• Galvanize New Research on Women’s Midlife Health .  To narrow research gaps on diseases and conditions associated with women’s midlife health or that are more likely to occur after menopause, such as rheumatoid arthritis, heart attack, and osteoporosis, the President is directing HHS to: expand data collection efforts related to women’s midlife health; launch a comprehensive research agenda that will guide future investments in menopause-related research; identify ways to improve management of menopause-related issues and the clinical care that women receive; and develop new resources to help women better understand their options for menopause-related symptoms prevention and treatment. The Executive Order also directs the DoD and VA to study and take steps to improve the treatment of, and research related to, menopause for Service women and women veterans.
• Assess Unmet Needs to Support Women’s Health Research . The Executive Order directs the Office of Management and Budget and the Gender Policy Council to lead a robust effort to assess gaps in federal funding for women’s health research and identify changes—whether statutory, regulatory, or budgetary—that are needed to maximally support the broad scope of women’s health research across the federal government. Agencies will also be required to report annually on their investments in women’s health research, as well as progress towards their efforts to improve women’s health.

Today, agencies are also announcing new actions they are taking to promote women’s health research , as part of their ongoing efforts through the White House Initiative on Women’s Health Research. Agencies are announcing actions to:

Prioritize and Increase Investments in Women’s Health Research

• Launch an NIH-Cross Cutting Effort to Transform Women’s Health Throughout the Lifespan. NIH is launching an NIH-wide effort to close gaps in women’s health research across the lifespan. This effort—which will initially be supported by $200 million from NIH beginning in FY 2025—will allow NIH to catalyze interdisciplinary research, particularly on issues that cut across the traditional mandates of the institutes and centers at NIH. It will also allow NIH to launch ambitious, multi-faceted research projects such as research on the impact of perimenopause and menopause on heart health, brain health and bone health. In addition, the President’s FY25 Budget Request would double current funding for the NIH Office of Research on Women’s Health to support new and existing initiatives that emphasize women’s health research.

This coordinated, NIH-wide effort will be co-chaired by the NIH Office of the Director, the Office of Research on Women’s Health, and the institute directors from the National Institute on Aging; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Institute on Arthritis, Musculoskeletal and Skin Diseases.

• Invest in Research on a Wide Range of Women’s Health Issues. The bipartisan Congressionally Directed Medical Research Program (CDMRP), led out of DoD, funds research on women’s health encompassing a range of diseases and conditions that affect women uniquely, disproportionately, or differently from men. While the programs and topic areas directed by Congress differ each year, CDMRP has consistently funded research to advance women’s health since its creation in 1993. In Fiscal Year 2022, DoD implemented nearly $490 million in CDMRP investments towards women’s health research projects ranging from breast and ovarian cancer to lupus to orthotics and prosthetics in women.  In Fiscal Year 2023, DoD anticipates implementing approximately $500 million in CDMRP funding for women’s health research, including in endometriosis, rheumatoid arthritis, and chronic fatigue.
• Call for New Proposals on Emerging Women’s Health Issues . Today, NSF is calling for new research and education proposals to advance discoveries and innovations related to women’s health. To promote multidisciplinary solutions to women’s health disparities, NSF invites applications that would improve women’s health through a wide range of disciplines—from computational research to engineering biomechanics. This is the first time that NSF has broadly called for novel and transformative research that is focused entirely on women’s health topics, and proposals will be considered on an ongoing basis.
• Increase Research on How Environmental Factors Affect Women’s Health. The Environmental Protection Agency (EPA) is updating its grant solicitations and contracts to ensure that applicants prioritize, as appropriate, the consideration of women’s exposures and health outcomes. These changes will help ensure that women’s health is better accounted for across EPA’s research portfolio and increase our knowledge of women’s environmental health—from endocrine disruption to toxic exposure.
• Create a Dedicated, One-Stop Shop for NIH Funding Opportunities on Women’s Health. Researchers are often unaware of existing opportunities to apply for federal funding. To help close this gap, NIH is issuing a new Notice of Special Interest that identifies current, open funding opportunities related to women’s health research across a wide range of health conditions and all Institutes, Centers, and Offices. The NIH Office of Research on Women’s Health will build on this new Notice by creating a dedicated one-stop shop on open funding opportunities related to women’s health research. This will make it easier for researchers and institutions to find and apply for funding—instead of having to search across each of NIH’s 27 institutes for funding opportunities.

Foster Innovation and Discovery in Women’s Health

• Accelerate Transformative Research and Development in Women’s Health. ARPA-H’s Sprint for Women’s Health launched in February 2024 commits $100 million to transformative research and development in women’s health. ARPA-H is soliciting ideas for novel groundbreaking research and development to address women’s health, as well as opportunities to accelerate and scale tools, products, and platforms with the potential for commercialization to improve women’s health outcomes.
• Support Private Sector Innovation Through Additional Federal Investments in Women’s Health Research. The NIH’s competitive Small Business Innovation Research Program and the Small Business Technology Transfer Program is committing to further increasing—by 50 percent—its investments in supporting innovators and early-stage small businesses engaged in research and development on women’s health. These programs will solicit new proposals on promising women’s health innovation and make evidence-based investments that bridge the gap between performance of basic science and commercialization of resulting innovations. This commitment for additional funds builds on the investments the Administration has already made to increase innovation in women’s health through small businesses, including by increasing investments by sevenfold between Fiscal Year 2021 and Fiscal Year 2023.
• Advance Initiatives to Protect and Promote the Health of Women. The Food and Drug Administration (FDA) seeks to advance efforts to help address gaps in research and availability of products for diseases and conditions that primarily impact women, or for which scientific considerations may be different for women, and is committed to research and regulatory initiatives that facilitate the development of safe and effective medical products for women. FDA also plans to issue guidance for industry that relates to the inclusion of women in clinical trials and conduct outreach to stakeholders to discuss opportunities to advance women’s health across the lifespan. And FDA’s Office of Women’s Health will update FDA’s framework for women’s health research and seek to fund research with an emphasis on bridging gaps in knowledge on important women’s health topics, including sex differences and conditions that uniquely or disproportionately impact women.
• Use Biomarkers to Improve the Health of Women Through Early Detection and Treatment of Conditions, such as Endometriosis. NIH will launch a new initiative dedicated to research on biomarker discovery and validation to help improve our ability to prevent, diagnose, and treat conditions that affect women uniquely, including endometriosis. This NIH initiative will accelerate our ability to identify new pathways for diagnosis and treatment by encouraging multi-sector collaboration and synergistic research that will speed the transfer of knowledge from bench to bedside.
• Leverage Engineering Research to Improve Women’s Health . The NSF Engineering Research Visioning Alliance (ERVA) is convening national experts to identify high-impact research opportunities in engineering that can improve women’s health. ERVA’s Transforming Women’s Health Outcomes Through Engineering visioning event will be held in June 2024, and will bring together experts from across engineering—including those in microfluidics, computational modeling, artificial intelligence/imaging, and diagnostic technologies and devices—to evaluate the landscape for new applications in women’s health. Following this event, ERVA will issue a report and roadmap on critical areas where engineering research can impact women’s health across the lifespan.
• Drive Engineering Innovations in Women’s Health Discovery . NSF awardees at Texas A&M University will hold a conference in summer 2024 to collectively identify challenges and opportunities in improving women’s health through engineering. Biomedical engineers and scientists will explore and identify how various types of engineering tools, including biomechanics and immuno-engineering, can be applied to women’s health and spark promising new research directions.

Expand and Leverage Data Collection and Analysis Related to Women’s Health

• Help Standardize Data to Support Research on Women’s Health. NIH is launching an effort to identify and develop new common data elements related to women’s health that will help researchers share and combine datasets, promote interoperability, and improve the accuracy of datasets when it comes to women’s health. NIH will initiate this process by convening data and scientific experts across the federal government to solicit feedback on the need to develop new NIH-endorsed common data elements—which are widely used in both research and clinical settings. By advancing new tools to capture more data about women’s health, NIH will give researchers and clinicians the tools they need to enable more meaningful data collection, analysis, and reporting and comprehensively improve our knowledge of women’s health.
• Reflect Women’s Health Needs in National Coverage Determinations. The Centers for Medicare & Medicaid Services (CMS) will strengthen its review process, including through Coverage with Evidence Development guidance, to ensure that new medical services and technologies work well in women, as applicable, before being covered nationally through the Medicare program. This will help ensure that Medicare funds are used for treatments with a sufficient evidence base to show that they actually work in women, who make up more than half of the Medicare population.
• Leverage Data and Quality Measures to Advance Women’s Health Research. The Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) are building on existing datasets to improve the collection, analysis, and reporting of information on women’s health. The CDC is expanding the collection of key quality measures across a woman’s lifespan, including to understand the link between pregnancy and post-partum hypertension and heart disease, and plans to release the Million Hearts Hypertension in Pregnancy Change Package. This resource will feature a menu of evidence-informed strategies by which clinicians can change care processes. Each strategy includes tested tools and resources to support related clinical quality improvement. HRSA is modernizing its Uniform Data System in ways that will improve the ability to assess how women are being served through HRSA-funded health centers. By improving the ability to analyze data on key clinical quality measures, CDC and HRSA can help close gaps in women’s health care access and identify new opportunities for high-impact research.  

Strengthen Coordination, Infrastructure, and Training to Support Women’s Health Research

• Launch New Joint Collaborative to Improve Women’s Health Research for Service Members and Veterans. DoD and VA are launching a new Women’s Health Research collaborative to explore opportunities that further promote joint efforts to advance women’s health research and improve evidence-based care for Service members and veterans. The collaborative will increase coordination with the goal of helping improve care across the lifespan for women in the military and women veterans. The Departments will further advance research on key women’s health issues and develop a roadmap to close pressing research gaps, including those specifically affecting Service women and women veterans.
• Coordinate Research to Advance the Health of Women in the Military. DoD will invest $10 million, contingent on available funds, in the Military Women’s Health Research Partnership. This Partnership is led by the Uniformed Services University and advances and coordinates women’s health research across the Department. The Partnership is supporting research in a wide range of health issues affecting women in the military, including cancers, mental and behavioral health, and the unique health care needs of Active Duty Service Women. In addition, the Uniformed Services University established a dedicated Director of Military Women’s Health Research Program, a role that is responsible for identifying research gaps, fostering collaboration, and coordinating and aligning a unified approach to address the evolving needs of Active Duty Service Women.
• Support EPA-Wide Research and Dissemination of Data on Women’s Health. EPA is establishing a Women’s Health Community of Practice to coordinate research and data dissemination. EPA also plans to direct the Board of Scientific Counselors to identify ways to advance EPA’s research with specific consideration of the intersection of environmental factors and women’s health, including maternal health.
• Expand Fellowship Training in Women’s Health Research. CDC, in collaboration with the CDC Foundation and American Board of Obstetrics and Gynecology, is expanding training in women’s health research and public health surveillance to OBGYNs, nurses and advanced practice nurses. Through fellowships and public health experiences with CDC, these clinicians will gain public health research skills to improve the health of women and children exposed to or affected by infectious diseases, mental health and substance use disorders. CDC will invite early career clinicians to train in public health and policy to become future leaders in women’s health research.

Improve Women’s Health Across the Lifespan

• Create a Comprehensive Research Agenda on Menopause. To help women get the answers they need about menopause, NIH will launch its first-ever Pathways to Prevention series on menopause and the treatment of menopausal symptoms. Pathways to Prevention is an independent, evidence-based process to synthesize the current state of the evidence, identify gaps in existing research, and develop a roadmap that can be used to help guide the field forward. The report, once completed, will help guide innovation and investments in menopause-related research and care across the federal government and research community.
• Improve Primary Care and Preventive Services for Women . The Agency for Healthcare Research and Quality (AHRQ) will issue a Notice of Intent to publish a funding opportunity announcement for research to advance the science of primary care, which will include a focus on women’s health. Through this funding opportunity, AHRQ will build evidence about key elements of primary care that influence patient outcomes and advance health equity—focusing on women of color—such as care coordination, continuity of care, comprehensiveness of care, person-centered care, and trust. The results from the funding opportunity will shed light on vital targets for improvements in the delivery of primary healthcare across a woman’s lifespan, including women’s health preventive services, prevention and management of multiple chronic diseases, perinatal care, transition from pediatric to adult care, sexual and reproductive health, and care of older adults.
• Promote the Health of American Indian and Alaska Native Women. The Indian Health Service is launching a series of engagements, including focus groups, to better understand tribal beliefs related to menopause in American Indian and Alaska Native Women. This series will inform new opportunities to expand culturally informed patient care and research as well as the development of new resources and educational materials.
• Connect Research to Real-World Outcomes to Improve Women’s Mental and Behavioral Health. The Substance Abuse and Mental Health Services Administration (SAMHSA) is supporting a range of health care providers to address the unique needs of women with or at risk for mental health and substance use disorders. Building on its current efforts to provide technical assistance through various initiatives , SAMHSA intends, contingent on available funds, to launch a new comprehensive Women’s Behavioral Health Technical Assistance Center. This center will identify and improve the implementation of best practices in women’s behavioral health across the life span; identify and fill critical gaps in knowledge of and resources for women’s behavioral health; and provide learning opportunities, training, and technical assistance for healthcare providers.
• Support Research on Maternal Health Outcomes. USDA will fund research to help recognize early warning signs of maternal morbidity and mortality in recipients of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and anticipates awarding up to $5 million in Fiscal Year 2023 to support maternal health research through WIC. In addition, research being conducted through the Agricultural Research Service’s Human Nutrition Research Centers is focusing on women’s health across the lifespan, including the nutritional needs of pregnant and breastfeeding women and older adults.

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Quantitative Biology > Quantitative Methods

Title: sequential inference of hospitalization electronichealth records using probabilistic models.

Abstract: In the dynamic hospital setting, decision support can be a valuable tool for improving patient outcomes. Data-driven inference of future outcomes is challenging in this dynamic setting, where long sequences such as laboratory tests and medications are updated frequently. This is due in part to heterogeneity of data types and mixed-sequence types contained in variable length sequences. In this work we design a probabilistic unsupervised model for multiple arbitrary-length sequences contained in hospitalization Electronic Health Record (EHR) data. The model uses a latent variable structure and captures complex relationships between medications, diagnoses, laboratory tests, neurological assessments, and medications. It can be trained on original data, without requiring any lossy transformations or time binning. Inference algorithms are derived that use partial data to infer properties of the complete sequences, including their length and presence of specific values. We train this model on data from subjects receiving medical care in the Kaiser Permanente Northern California integrated healthcare delivery system. The results are evaluated against held-out data for predicting the length of sequences and presence of Intensive Care Unit (ICU) in hospitalization bed sequences. Our method outperforms a baseline approach, showing that in these experiments the trained model captures information in the sequences that is informative of their future values.

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Catherine, Princess of Wales, Reveals She Has Cancer

The princess described the news as a “huge shock” and asked for “time, space and privacy” in a prerecorded video broadcast on the BBC on Friday evening in Britain.

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Princess of Wales Announces Cancer Diagnosis

In a video statement, catherine, princess of wales, said that she had been diagnosed with cancer and started chemotherapy..

I wanted to take this opportunity to say thank you personally for all the wonderful messages of support and for your understanding whilst I’ve been recovering from surgery. It has been an incredibly tough couple of months for our entire family. But I’ve had a fantastic medical team who have taken great care of me, for which I’m so grateful. In January, I underwent major abdominal surgery in London, and at the time, it was thought that my condition was noncancerous. The surgery was successful. However, tests after the operation found cancer had been present. My medical team therefore advised that I should undergo a course of preventative chemotherapy, and I’m now in the early stages of that treatment. This, of course, came as a huge shock, and William and I have been doing everything we can to process and manage this privately for the sake of our young family. As you can imagine, this has taken time. It has taken me time to recover from major surgery in order to start my treatment. But most importantly, it has taken us time to explain everything to George, Charlotte and Louis in a way that’s appropriate for them and to reassure them that I’m going to be OK. As I’ve said to them, I am well. And getting stronger every day, by focusing on the things that will help me heal, in my mind, body and spirits. Having William by my side is a great source of comfort and reassurance, too, as is the love, support and kindness that has been shown by so many of you. It means so much to us both. We hope that you’ll understand that as a family, we now need some time, space and privacy while I complete my treatment. My work has always brought me a deep sense of joy, and I look forward to being back when I’m able. But for now, I must focus on making a full recovery. At this time, I’m also thinking of all those whose lives have been affected by cancer. For everyone facing this disease, in whatever form, please do not lose faith or hope. You are not alone.

Mark Landler

Reporting from London

Here’s the latest on the Princess of Wales’s cancer news.

Catherine, Princess of Wales, has been diagnosed with cancer and has begun chemotherapy, she announced in a video message on Friday, in which she described the past two months as “incredibly tough for our entire family.”

Her diagnosis follows that of King Charles III , who announced his own cancer diagnosis and treatment in early February. It comes after a period of intense uncertainty about the health of Catherine, who underwent abdominal surgery in January and largely disappeared from public view as she tried to recuperate.

Like the king, Catherine, 42, did not specify what kind of cancer she had but asked the public and news media to respect her desire for privacy.

“We hope that you will understand that, as a family, we now need some time, space and privacy while I complete my treatment,” said Catherine, who is the wife of Prince William and a future queen.

“This of course came as a huge shock,” Catherine said, “and William and I have been doing everything we can to process and manage this privately for the sake of our young family. As you can imagine, this has taken time.”

Catherine’s announcement is a grim coda to a period of increasingly wild rumors about her health and well-being. But it plunges the British royal family into a period of even deeper uncertainty, with both the 75-year-old monarch and his daughter-in-law, the wife of his eldest son and heir and the mother of Prince George, the second in line to throne, facing grave health problems.

In her statement, Catherine said that at the time her surgery was performed, doctors believed that her condition was noncancerous. The surgery was successful, she said, but in further tests, the doctor found evidence of cancer. They recommended a course of chemotherapy, which she said she had recently begun.

“It has taken me time to recover from major surgery in order to start my treatment,” Catherine said in the video. “But, most importantly, it has taken us time to explain everything to George, Charlotte and Louis in a way that is appropriate for them, and to reassure them that I am going to be OK.”

Catherine’s announcement eerily echoed that of Charles’s. Buckingham Palace said that the king’s cancer was detected after a procedure for an enlarged prostate. While the palace has said he does not have prostate cancer, it has not specified what kind of cancer it is, nor his prognosis.

Until Catherine’s video on Friday, Kensington Palace, where William and Catherine have their offices, had released even fewer details about her condition, an information vacuum that led to a raft of rumors and conspiracy theories on social media .

In the video, which Kensington Palace said was recorded by BBC Studios in Windsor on Wednesday, Catherine is sitting on a bench outside, with daffodils and trees in blossom behind her.

Her hands clasped on her lap, she begins by thanking the public for their messages of support and understanding while she was recovering from surgery, before announcing her diagnosis.

“In January, I underwent major abdominal surgery in London, and, at the time, it was thought that my condition was noncancerous. The surgery was successful,” she said. “However, tests after the operation found cancer had been present. My medical team therefore advised that I should undergo a course of preventative chemotherapy, and I am now in the early stages of that treatment.”

Catherine’s statement emphasized the importance of her three children and their well-being as a key factor in the timing of the announcement. “As I have said to them,” she said, “I am well and getting stronger every day by focusing on the things that will help me heal; in my mind, body and spirits. Having William by my side is a great source of comfort and reassurance, too.”

The children’s school has now closed for the Easter holidays. A Kensington Palace official said Catherine and William had wanted to share the information when they felt it was right for them as a family.

Catherine ended her video statement with a message for other people affected by a cancer diagnosis. “At this time, I am also thinking of all those whose lives have been affected by cancer,” she said. “For everyone facing this disease, in whatever form, please do not lose faith or hope. You are not alone.”

Gina Kolata

Gina Kolata previously reported on King Charles III’s cancer diagnosis .

Doctors recognize familiar pattern in the princess’s statement.

Although it is not known what type of cancer Princess Catherine has, oncologists say that what she described in her public statement that was released on Friday — discovering a cancer during another procedure, in this case a “major abdominal surgery” — is all too common.

“Unfortunately, so much of the cancer we diagnose is unexpected,” said Dr. Elena Ratner, a gynecologic oncologist at Yale Cancer Center who has diagnosed many patients with ovarian cancer, uterine cancer and cancers of the lining of the uterus.

Without speculating on Catherine’s procedure, Dr. Ratner described situations in which women will go in for surgery for endometriosis, a condition in which tissue similar to the lining of the uterus is found elsewhere in the abdomen. Often, Dr. Ratner says, the assumption is that the endometriosis has appeared on an ovary and caused a benign ovarian cyst. But one to two weeks later, when the supposedly benign tissue has been studied, pathologists report that they found cancer.

In the statement, Princess Catherine said she is getting “a course of preventive chemotherapy.”

That, too, is common. In medical settings, it is usually called adjuvant chemotherapy.

Dr. Eric Winer, director of the Yale Cancer Center, said that with adjuvant chemotherapy, “the hope is that this will prevent further problems” and avoid a recurrence of the cancer.

It also means that “you removed everything” that was visible with surgery, said Dr. Michael Birrer, director of the Winthrop P. Rockefeller Cancer Institute at the University of Arkansas for Medical Sciences. “You can’t see the cancer,” he added, because microscopic cancer cells may be left behind. The chemotherapy is a way to attack microscopic disease, he explained.

Other parts of Catherine’s statement also hit home for Dr. Ratner, particularly her concern for her family.

“William and I have been doing everything we can to process and manage this privately for the sake of our young family,” Catherine said, and “It has taken us time to explain everything to George, Charlotte, and Louis in a way that is appropriate for them, and to reassure them that I am going to be OK.”

Those are sentiments that Dr. Ratner hears on a regular basis and reveal, she says, “how hard it is for women to be diagnosed with cancer.”

“I see this day in and day out,” she said. “Women always say, ‘Will I be there for my kids? What will happen with my kids?’

“They don’t say, ‘What will happen to me?’”

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Another heavy blow for the British royal family.

For the royal family, the news of a cancer diagnosis for Catherine, Princess of Wales, was another heavy blow, sidelining one of its most visible figures at a time when its ranks were already depleted.

In addition to King Charles III, who has canceled public appearances to undergo his own cancer treatment, the family has been adjusting to the loss of Queen Elizabeth II, who died in 2022; the departure of Prince Harry and his wife, Meghan; and the exile of Prince Andrew, disgraced by his association with the convicted sex offender Jeffrey Epstein.

Harry and Meghan issued a statement saying they wished “health and healing for Kate and the family, and hope they are able to do so privately and in peace.”

Since Harry and Meghan, who are known as the Duke and Duchess of Sussex, withdrew from royal duties in 2020 and left Britain for Southern California, Harry has been estranged from his father, Charles, and his brother, Prince William. He visited his father briefly after Buckingham Palace announced the king’s cancer diagnosis in February.

The palace said on Friday that Charles was “so proud of Catherine for her courage in speaking as she did.” Noting that the king had visited her when they were both being treated in a London hospital, the palace said Charles “has remained in the closest contact with his beloved daughter-in-law throughout the past weeks.”

Buckingham Palace said only last month that King Charles has cancer.

King Charles III was diagnosed with cancer in early February and suspended his public engagements to undergo treatment, casting a shadow over a busy reign that began around 18 months ago after the death of his mother, Queen Elizabeth II.

The announcement, made by Buckingham Palace, came after the 75-year-old sovereign was discharged from a London hospital, following a procedure to treat an enlarged prostate.

The palace did not disclose what form of cancer Charles has, but a palace official said it was not prostate cancer. Doctors detected the cancer during that procedure, and the king began treatment on Monday.

News of Charles’ diagnosis ever since has reverberated through Britain, which, after seven decades of Elizabeth’s reign, has begun to get comfortable with her son. Charles waited longer to ascend the throne than anyone in the history of the British monarchy, and he was a familiar figure, with a personal life relentlessly dissected by the British media by the time he became the sovereign.

Nate Schweber

The mood is somber at a British outpost in New York.

The mood was somber Friday afternoon in the section of Manhattan’s West Village that some people call Little Britain after Catherine, Princess of Wales, announced that she was being treated for cancer.

At Myers of Keswick, a shop on Hudson Street that sells British goods like Hobnobs biscuits, Wilkin & Sons marmalade and steak and ale pie, Jennifer Myers-Pulidore, the owner, said she had watched the announcement live while fielding alarmed texts from her father, Peter Myers. He opened the store 39 years ago and is now retired and living back in Keswick, England.

“I feel for her,” said Ms. Myers-Pulidore, 45, who was born in New York and grew up spending summers in Keswick. With three children of her own, she said she could relate to the princess’s desire to address the matter with her family before discussing it publicly.

“I understand wanting to protect the children,” Ms. Myers-Pulidore said. “I can’t imagine living in the limelight as they do.”

She said she had not kept up with the recent wave of speculation online about why Catherine had not been seen much in public since undergoing abdominal surgery earlier this year. Ms. Myers-Pulidore had nothing good to say about those who had spread wild rumors.

“It’s awful. It’s sort of pathetic that she couldn’t even have time in private,” she said. “It almost makes me think she had no other option but to come clean.”

For Ms. Myers-Pulidore, the news stirred painful memories of Princess Diana, a previous Princess of Wales to whom the store owner considers Catherine a spiritual heir.

“She, in England, is loved,” Ms. Myers-Pulidore said of Catherine. “People think of her as the people’s princess.”

After Diana’s death; the death of Queen Elizabeth II; King Charles’s cancer diagnosis; and estrangement between William, Prince of Wales, and his brother, Prince Harry, the Duke of Sussex, Ms. Myers-Pulidore said she worried about the British royal family’s future.

“I hope they will make it,” she said.

Outside the shop, Richard Barnett winced while discussing the news.

“It’s all very sad,” said Mr. Barnett, a London native who has lived in New York for 35 years. He added that he hoped Catherine’s treatment would be successful and that her recovery would be swift and comfortable.

“Wish her the best,” he said. “And peace and quiet.”

Asked whether he had followed the recent gossip and speculation about Catherine that Ms. Myers-Pulidore had condemned, Mr. Barnett nodded.

“It’s good she stopped the rumors,” he said.

Outside Tea & Sympathy, a British restaurant a few blocks away on Greenwich Avenue, Dave Heenan shook his head when asked about the news.

“It’s awful. I’m devastated — the whole royal family, they’re cursed!” said Mr. Heenan, 81, who moved to New York from Newcastle, England, in 1963. He said that, like other British people, he had come to love Catherine and was excited about her future.

“She’s the one member of the royal family who could really carry that crown,” he said.

One positive thing he could say was that he had been able to share his feelings with fellow English men and women: “It brings English people together.”

Iain Anderson, Tea & Sympathy’s manager, said he had become concerned about Catherine recently as she stayed out of the public eye and rumors about her flew. He said that to him, the announcement on Friday felt forced.

“Maybe they had to say something because of the public pressure,” Mr. Anderson, who is originally from Gloucestershire, England, said. “If they had to open up about this and they didn’t want to, that’s unfortunate.”

Like Ms. Myers-Pulidore, he said he had a grim feeling of déjà vu.

“We’ve had all this before with Lady Diana,” he said

Michael West, a Briton living in Manhattan, said he was reminded of Queen Elizabeth II’s death two years ago as well as King Charles’s cancer diagnosis.

“It just seems as though trouble comes in threes,” he said as he passed the British Consulate on Second Avenue. “And it just seems as though, for that family at the moment, that perhaps trouble comes in tens.”

Mr. West is originally from a village called Higham, famous as the place where Charles Dickens died. He said that although Catherine had not been born into royalty, she had fit well into her role as a Windsor.

“Among my family and friends, people were happy with them,” he said of the family, adding, “They do their job with grace.”

Sean Piccoli contributed reporting.

Megan Specia

The reaction of Londoners is full of concern.

As news filtered out about the princess of Wales’s cancer diagnosis in London on Friday, just as the sun was setting on a mild spring evening, many expressed their shock and concern for a well-liked member of the British royal family, who is destined to one day be queen.

Kensington Palace had urged the public to respect the privacy of Catherine as she recovered from a major abdominal surgery in January, but as the days drew into weeks, the rumor mill swirled — with conspiracy theories growing deeper and wilder — about what had been keeping such a prominent member of the royal family out of view.

On Friday evening, many lamented the scrutiny she had faced and what the family had been forced to endure at such a terrible time.

“She is still just a human,” said Aaron Viera, 33, and a lifelong Lononder. “It’s just really sad that she has to go through this.”

Alongside co-workers sharing a drink outside the Goat Tavern, just steps from Kensington Palace where Catherine and her family had lived, Mr. Viera denounced the social media speculation.

Much of that frenzy has been driven by an American “obsession” with the royals, interjected another friend, Maryann, 35, who declined to give her last name. At the end of the day, she’s a mother of three, another woman, Jessi, pointed out, and she worried about toll chemotherapy would take on Catherine. So many in the country know the struggles of cancer personally, and they agreed that Catherine’s candor about her illness unfortunately would be easy for many to relate to.

Catherine, 42, the wife of William, Prince of Wales, is the second member of the British royal family to be diagnosed with cancer in recent weeks after Buckingham Palace announced in February that her father-in-law, King Charles III , also was being treated for cancer.

On Friday evening, the overwhelming sentiment seemed to be of concern for the well-being of the princess of Wales.

“God, she’s had cancer, has she?” one woman said to her friend, engrossed in a news article on her phone while getting off a bus in the northwest of the city. “Terrible, she’s only 40-something, isn’t she?”

The New York Times

Read Catherine’s full statement.

A transcript of the video message given by Catherine, princess of Wales:

I wanted to take this opportunity to say thank you, personally, for all the wonderful messages of support and for your understanding whilst I have been recovering from surgery. It has been an incredibly tough couple of months for our entire family, but I’ve had a fantastic medical team who have taken great care of me, for which I am so grateful. In January, I underwent major abdominal surgery in London and at the time, it was thought that my condition was noncancerous. The surgery was successful. However, tests after the operation found cancer had been present. My medical team therefore advised that I should undergo a course of preventative chemotherapy and I am now in the early stages of that treatment. This of course came as a huge shock, and William and I have been doing everything we can to process and manage this privately for the sake of our young family. As you can imagine, this has taken time. It has taken me time to recover from major surgery in order to start my treatment. But, most importantly, it has taken us time to explain everything to George, Charlotte and Louis in a way that is appropriate for them, and to reassure them that I am going to be OK. As I have said to them; I am well and getting stronger every day by focusing on the things that will help me heal; in my mind, body and spirits. Having William by my side is a great source of comfort and reassurance too. As is the love, support and kindness that has been shown by so many of you. It means so much to us both. We hope that you will understand that, as a family, we now need some time, space and privacy while I complete my treatment. My work has always brought me a deep sense of joy and I look forward to being back when I am able, but for now I must focus on making a full recovery. At this time, I am also thinking of all those whose lives have been affected by cancer. For everyone facing this disease, in whatever form, please do not lose faith or hope. You are not alone.

Derrick Bryson Taylor

A timeline of the royal family’s tumultuous year.

• Outside Kensington Palace. Henry Nicholls/Agence France-Presse — Getty Images
• Catherine, Princess of Wales, made her announcement on a video. Oli Scarff/Agence France-Presse — Getty Images
• Watching the announcement outside Buckingham Palace. Hollie Adams/Reuters
• Prince William and Princess Catherine in Cardiff, Wales, in October. Chris Jackson/Getty Images
• A reporter outside the London Clinic, a private hospital where Catherine had surgery in January. Tolga Akmen/EPA, via Shutterstock
• Catherine in May at King Charles III's coronation. Odd Andersen/Agence France-Presse — Getty Images
• Watching a news report at a hotel pub in Newcastle-under-Lyme. Carl Recine/Reuters

Since King Charles III and Catherine, the Princess of Wales, each went to hospitals for health matters in recent months, public attention has been riveted on the royal family. The extended absence of Kate from the public eye, especially, propelled a wave of rumors over her whereabouts, fueled further by an edited photo released by the palace.

Here is a quick timeline of key moments.

Jan. 17, 2024

Kate undergoes surgery.

A little more than three weeks after Kate made a public appearance on Christmas Day, Kensington Palace announced that she had been admitted to the London Clinic to have abdominal surgery . Officials gave few details about her health but said the surgery was successful, and that her condition was “not cancerous.”

Hours later, Buckingham Palace announced that King Charles III would be treated for an enlarged prostate.

Jan. 29, 2024

Kate is released from the hospital.

Almost two weeks later, Kate returned home to Windsor, just outside London . Kensington Palace officials said that she would convalesce at home for two to three months and would not resume her public duties until after Easter, at the end of March.

Feb. 5, 2024

King Charles is diagnosed with cancer.

Buckingham Palace officials announced in early February, just days after Charles had undergone treatment for an enlarged prostate, that the king had been diagnosed with cancer .

The palace did not share what form of cancer Charles has, but a palace official said it was not prostate cancer. Doctors had discovered the cancer during the earlier procedure.

March 4, 2024

Kate is spotted for the first time in months.

The public’s appetite for information about Kate’s whereabouts and recovery reached a fever pitch in the first week of March. And around that time, TMZ published a grainy paparazzi shot of Kate riding in a car driven by her mother.

Despite the photograph circulating on the internet, British newspapers and broadcasters did not republish it, citing Kate’s request for privacy during her convalescence — though they did report on the sighting.

March 10, 2024

Kate and children appear in Mother’s Day photograph.

To mark Mother’s Day in Britain, Kensington Palace released an official photograph of a smiling Kate surrounded by her three children, George, Charlotte and Louis. The palace did not give many details about the picture except that it was taken by William last week in Windsor, where the family lives in Adelaide Cottage, on the grounds of Windsor Castle.

While the picture was meant to highlight a happy family on the holiday and quell rumors, it became a subject of intense scrutiny after The Associated Press, and several other photo agencies, issued a “kill order,” asking its clients to remove it from all platforms over concerns that it had been manipulated. The New York Times, which had initially used the picture in a story, also removed it.

March 11, 2024

Kate apologizes for the altered photo.

On Monday, Kate took the blame and apologized for the Mother’s Day photo.

“Like many amateur photographers, I do occasionally experiment with editing,” she said on social media. “I wanted to express my apologies for any confusion the family photograph we shared yesterday caused.”

Kate is known as a photography enthusiast, and the palace often distributes her photos of the family. Palace officials stressed that Kate made minor adjustments for what was intended to be an informal family picture that was taken by William.

March 18, 2024

Another royal photo is flagged.

Getty Images placed an editorial advisory on a second royal family photo, this time an image of Queen Elizabeth II, flanked by her grandchildren and great-grandchildren. The photo — taken by Kate at Balmoral Castle in Scotland in August 2022 and released in 2023 on what would have been the queen’s 97th birthday — had been “digitally enhanced” before it was released by the palace, the photo agency said.

Mark Landler and Lauren Leatherby

Speculation had swirled since the Princess of Wales apologized for an edited image a week ago.

Zipper and hair are

Portion of sleeve is

Edges of tiles appear

Hair has artificial pattern

Hair has artificial

Catherine, the Princess of Wales, apologized last week for doctoring a photo of her with her three children, which was recalled by several news agencies after they determined the image had been manipulated .

The decision to recall the photo reignited a storm of speculation about Catherine, who had not been seen in public since Christmas Day and had abdominal surgery in January. In her statement, the 42-year-old princess chalked up the alteration to a photographer’s innocent desire to retouch the image.

“Like many amateur photographers, I do occasionally experiment with editing,” Catherine wrote in a post on social media. “I wanted to express my apologies for any confusion the family photograph we shared yesterday caused.”

The photo, which marked Mother’s Day in Britain, depicted a smiling Catherine surrounded by her children, George, Charlotte and Louis.

Kensington Palace said that William had taken the photo last week in Windsor, where the family lives in Adelaide Cottage, on the grounds of Windsor Castle. But Catherine is known as a keen photographer, and the palace often distributes her photos of the family.

Hours after Kensington Palace released the photo, The Associated Press, Reuters and Agence France-Presse issued advisories urging news organizations to remove the image.

The A.P. said that after a post-publication inspection of the photograph, its editors determined that the image “shows an inconsistency in the alignment of Princess Charlotte’s left hand.” The source of the photo, it said “had manipulated the image in a way that does not meet A.P.’s photo standards.”

Like many amateur photographers, I do occasionally experiment with editing. I wanted to express my apologies for any confusion the family photograph we shared yesterday caused. I hope everyone celebrating had a very happy Mother’s Day. C — The Prince and Princess of Wales (@KensingtonRoyal) March 11, 2024

The details of the photo show a range of visual inconsistencies suggesting it was doctored. In several areas of the image, details like a sleeve or a zipper don’t line up, or have artificial patterns.

A palace official said Catherine made minor adjustments in what was meant to be an informal picture of the family together for Mother’s Day. The official reiterated that William had taken the photo, though Catherine edited it.

Samora Bennett-Gager, an expert in photo retouching, identified several other questionable elements, including the edges of her daughter Charlotte’s legs, which he said were unnaturally soft, suggesting the background had been manipulated. Catherine’s hand on the waist of her son, Louis, is blurry, which he said could indicate the image was taken from a separate frame of the shoot.

The photograph appeared on newspaper front pages and websites around the world, including the website of The New York Times. The Times removed the photo from an article about it on Sunday evening.

Adam Dean contributed reporting.