Any patient scheduled for surgery or an invasive procedure must have a complete history and physical examination [H & P] completed within 30 days of the procedure date. The H & P must be dated, timed, and signed. If you are a member of the UCLA Santa Monica Medical Staff, you must also include your MD ID number [pager number].
The H & P must include a chief complaint, history of present illness, a review of systems, past surgical history, family history, social history, medication list, allergies, and results of a physical examination including vital signs.
Key Points:
- Review overseas medical documents, including vaccinations and screening for communicable conditions of public health importance
- Work with a qualified medical interpreter who speaks the patient’s preferred language
- During the initial screening appointment, address immediate health concerns/priority needs and obtain a detailed history, including aspects unique to refugees [e.g., travel history].
- Measure blood pressure [≥3 years], and complete a formal vision [≥3 years] and hearing screening [≥4 years]
- Conduct a thorough, head-to-toe physical exam as permitted by the patient, as this may reveal undiagnosed underlying diseases and other medical issues.
Background
Depending on their country of origin, refugees may be at increased risk for infectious or non-infectious conditions less commonly seen among the US-born population. The domestic refugee medical screening examination, conducted soon after US arrival, offers a timely opportunity to identify acute and chronic health conditions. The initial history and physical examination are critically important to identify and manage acute and chronic health conditions. The domestic medical screening also helps refugees develop a sense of trust in the US medical system and healthcare providers. Lastly, the domestic medical screening is an opportunity to introduce [or reaffirm] the importance of preventative medicine and routine physical examinations, as well as how and when to access emergency medical care.
Overseas Medical Examination: History and Physical
The overseas medical examination includes a medical history and physical examination to determine the presence and severity of Class A or Class B conditions. Panel physicians obtain a medical history, including current symptoms, significant acute or chronic conditions, and past hospitalizations and/or institutionalizations for chronic conditions.
Panel physicians conduct a review of systems and document symptoms that may suggest cardiovascular, pulmonary, musculoskeletal, or neuropsychiatric disorders. The physical examination is comprised of:
- Mental status examination [relevant for age] that includes an assessment of intelligence, thought, cognition [comprehension], judgment, affect [and mood], behavior, and appropriate development for young children;
- Physical examination including, a minimum of: examination of the eyes, ears, nose and throat, extremities, heart, lungs, abdomen, lymph nodes, and skin;
- Diagnostic tests required to identify communicable diseases of public health significance, as well as other tests identified as necessary to confirm a suspected diagnosis of any other Class A or Class B condition.
Details of the overseas history and physical examination may be found in the Technical Instructions for Panel Physicians.
Recommendations for New Arrival History and Physical Examination
The domestic medical screening is likely a refugee’s first routine medical encounter with the US-healthcare system and is an opportunity to begin establishing a trusting patient-provider relationship. It is critical to use qualified medical interpreters for any patient with limited English proficiency. Individuals should be assured that this confidential medical visit is for their health, does not have any regulatory purposes, and will not affect their resettlement or visa status. During the initial screening appointment, providers should review overseas medical documents, address a refugee’s immediate health concerns and priority needs as well as obtain a detailed history, including documentation of standard past medical history, medications, allergies, and social and family history. Additionally, a thorough history must include aspects unique to refugees, such as a history of toxic environmental exposures, dietary history, and travel/geographic history.
Past Medical History
A detailed past medical history may be difficult to obtain due to lack of recall, accurate prior diagnoses, lack of access to medical care overseas, or differing cultural beliefs around health and disease. Items more likely to be recalled and reported are prior hospitalizations, episodes of severe illness, known chronic conditions, previous injuries, surgeries [including dental procedures], circumcision, and blood transfusions. Additionally, refer to any medical documentation accompanying the refugee [e.g., Department of State [DS] forms] for documentation of medical conditions, including conditions that may have been identified during the overseas medical examination.
Vaccination History
Vaccinations must be reviewed. Historical vaccination records may include refugee camp vaccination cards and records or booklets from other programs or clinics. Some vaccinations, such as those administered through the Vaccination Program for US-Bound Refugees, will also be documented on the DS-3025 [Vaccination Worksheet]. In some instances, vaccinations given immediately before travel may be documented on the Pre-departure Medical Screening [PDMS] forms. For additional information, refer to the Guidance for Evaluating and Updating Immunizations during the Domestic Medical Examination for Newly Arrived Refugees.
Medication History
Medication history should include prescription and nonprescription medications. If a refugee is taking prescription medications, they should be provided with a minimum 30-day supply prior to departure. Details of dosing should be documented on the DS forms. Medication history should also include the use of traditional or herbal remedies and therapies with special attention to any products that may have potential drug interactions, teratogenicity, or be contaminated with toxins such as lead [see Screening for Lead during the Domestic Medical Examination for Newly Arrived Refugees for additional information] [1–3].
Family Medical History
A family history should be obtained. A detailed family history may be limited due to lack of access to medical care in a refugee’s country of origin, uncertainty around which family members to include [family members included in this history should be outlined by the provider], or lack of recall. Information about major conditions should be solicited [e.g., diabetes, asthma, seizures, sickle cell anemia, and hypertension].
Social History
A detailed social history should also be obtained, including housing, food, and schooling before and after arrival in the US. The current living situation and family structure should be ascertained, including the current support network and safety at home. Occupational history may raise suspicion about the patient’s and family members’ past environmental and chemical exposures. Education and literacy levels [including ability to read numbers] should be determined. This information should be used to ensure that health information and other resources are provided at an appropriate level and format [e.g., written, recorded, and/or pictograms]. Education and literacy levels may assist in placement in the appropriate school year for children and adolescents [see Incorrect Date of Birth [Chronological Age Discrepancy] in the Key Considerations and Best Practices for additional information].
Travel History
Country of birth, migration history, and where a patient resided before arrival in the US allow clinicians to determine potential travel-related/geographic infectious disease risks, environmental exposures, and potentially significant recent stressors.
Environmental Exposures
In-home exposure to tobacco smoke and smoke from cooking or heating sources should be determined, as well as exposure risks from work sites and residences. Lead exposure risks should be evaluated. This includes cosmetics, cookware, pottery, home remedies, and exposure to lead in gasoline and contaminated soil. Clinicians should refer to Screening for Lead during the Domestic Medical Examination for Newly Arrived Refugees for additional guidance.
Substance Use History
Clinicians should inquire about alcohol, tobacco, and illicit drug use. Additionally, secondhand smoke exposure risk should be obtained, as well as other substances that have significant known associated morbidity and may have potential legal ramifications [e.g., khat].
Mental Health History
A mental health screen and/or clinical evaluation should be performed with the assurance that those with identified mental health needs are linked to appropriate services. Refer to the Domestic Mental Health Screening Guidance for more specific screening recommendations for adults and children.
Sexual History
For women and adolescent girls, the following components of a sexual history should be obtained: reproductive history, menstrual history [including last menstrual period], history of contraceptive use, and risk for early pregnancy [i.e., date of last unprotected sex relative to last menstrual period]. This will help guide decision-making around contraception, if desired, and the potential need for repeat pregnancy testing or emergency contraception.
For all men and women, including teenagers, it is important to determine the date of last unprotected sex to ascertain if there is a need for repeat testing for sexually transmitted infections [i.e., HIV, hepatitis B and C, syphilis, gonorrhea, and chlamydia].
Refer to the Sexual and Reproductive Health Domestic Screening Guidance for more detailed information.
Review of Systems
A detailed review of systems should be obtained, keeping in mind particular infections or illnesses that the patient may have based on travel history, country of origin, environmental exposures, and history of trauma. Signs and symptoms such as fever, weight loss, night sweats, pulmonary complaints, diarrhea, abdominal complaints, pruritis, and skin lesions or rashes are particularly important.
Performing the Physical Exam
The physical examination can identify important health issues that need to be addressed at the domestic medical screening and chronic conditions that require further evaluation and management. A thorough, head-to-toe physical exam is critical and may reveal underlying diseases and medical issues. For many refugees, this may be the first comprehensive exam they have experienced. Steps should be clearly explained, using a professional medical interpreter, with gender-concordant examiners provided, if requested and feasible.
Vital Signs
Vital signs, including temperature, heart rate, and respiratory rate, should be measured in all patients. Measure blood pressure in all patients ≥3 years old [routine blood pressure measurement is not done overseas in children under 15 years]. Clinicians who see children at the domestic medical screening should refer to Pediatric Blood Pressure Norms [PDF – 4 pages] for additional information. Weight and height [supine measurement if