Physical Examination and History Taking with complete solutions.
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Course
History and Physical
Institution
History And Physical
Subjective data
What the patient tells you. The history, from Chief Complaint through review of Systems.
Objective data
What you detect during the examination. All physical examination findings.
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Physical Examination and History
Taking with complete solutions
Subjective data - ANSWER- What the patient tells you. The history, from Chief
Complaint through review of Systems.
Objective data - ANSWER- What you detect during the examination. All physical
examination findings.
Seven components of the Comprehensive Adult Health History - ANSWER- -
Identifying Data and Source of the History
- Chief Complaint(s)
- Present Illness
- Past History
- Family History
- Personal and Social History
- Review of Systems
The Physical Examination - ANSWER- - General Survey
- Vital Signs
- Skin
- HEENT
- Neck
- Back
- Posterior Thorax and Lungs
- Breasts, Axillae, and Epitrochlear Nodes
- Anterior Thorax and Lungs
- Cardiovascular System
- Abdomen
- Lower Extremities
, - Nervous System
Comprehensive Assessment - ANSWER- - Is appropriate for new patients in the
office or hospital
- Provides fundamental and personalized knowledge about the patient
- Strengthens the clinician-patient relationship
- Helps identify or rule out physical causes related to patient concerns
- Provides baselines for future assessments
- Creates platform for health promotion through education and counseling
- Develops proficiency in the essential skills of physical examination
Focused Assessment - ANSWER- - Is appropriate for established patients,
especially during routine or urgent care visits
- Addresses focused concerns or symptoms
- Assess symptoms restricted to specific body system
- Applies examination methods relevant to assessing the concern or problem as
precisely and carefully as possible
Identifying Data - ANSWER- - Identifying data- such as age, gender, occupation,
marital status
- Source of history- usually the patient, but can be a family member or friend,
letter of referral, or the medical record
- If appropriate, establish source of referral, because a written report may be
needed
Reliability - ANSWER- - Varies according to the patient's memory, trust, and mood
Chief Complaint(s) - ANSWER- The one or more symptoms or concerns causing
the patient to seek care
Present Illness - ANSWER- - Amplifies the Chief Complaint; describes how each
symptom developed
- Includes patient's thoughts and feelings about the illness
- Pulls in the relevant portions of the Review of Systems, called "pertinent
positives and negatives"
- May include medications, allergies, and habits of smoking and alcohol, which
are frequently pertinent to the present illness
- Complete, clear, and chronologic account of the problems prompting the patient
to seek care
- Should be well- characterized with descriptions of (1) location; (2) quality; (3)
quantity or severity; (4) timing, including onset, duration, and frequency; (5) the
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