1
,2
, ● Develops proficiency in the essential skills of physical
examination
Flexible Focused or problem-oriented assessment:For patients you know well returning for
routine care, or those with specific ―urgent care‖ concerns like sore throat or knee pain. You will
adjust the scope of your history and physical examination to the situation at hand, keeping
several factors in mind: the magnitude and severity of the patient’s problems; the need for
thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the
time available.
●Is appropriate for established patients, especially during routine
or urgent care visits
●Addresses focused concerns or symptoms
●Assesses symptoms restricted to a specific body system
●Applies examination methods relevant to assessing the concern or
problem as thoroughly and carefully as possible
Tangential lighting: JVD, thyroid gland, and apical impulse of heart.
Components of the Health History Jenna/Ashley
Initial information
Identifying data and source of the history; reliability
Identifying data- age, gender, occupation, marital status
Source of history- usually patient. Can be: a family member or friend, letter of referral, or
clinical record.
Reliability- Varies according to the patient’s memory, trust, and mood.
Chief Complaint
, Chief Complaint- Make every attempt to quote the patient’s own words.
Present Illness
Complete, clear and chronological description of the problem prompting the patient visit
Onset, setting in which it occurred, manifestations and any treatments
Should include 7 attributes of a symptom:
●Location
●Quality
●Quantity or severity
●Timing, onset, duration, frequency
●Setting in which it occurs
●Aggravating or relieving factors
● Associated manifestations
-Differential diagnosis is derived from the ―pertinent positives‖ and ―pertinent negatives‖ when
doing Review of Systems that are relevant to the chief complaint. A list of potential causes for
the patients problems.
-Present illness should reveal patient’s responses to his or her symptoms and what effect this has
on their life.
-Each symptom needs its own paragraph and a full description.
-Medication should be documented, name, dose, route, and frequency. Home remedies, non-
prescriptions drugs, vitamins, minerals or herbal supplements, oral contraceptives, or borrowed
medications.
,2
, ● Develops proficiency in the essential skills of physical
examination
Flexible Focused or problem-oriented assessment:For patients you know well returning for
routine care, or those with specific ―urgent care‖ concerns like sore throat or knee pain. You will
adjust the scope of your history and physical examination to the situation at hand, keeping
several factors in mind: the magnitude and severity of the patient’s problems; the need for
thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the
time available.
●Is appropriate for established patients, especially during routine
or urgent care visits
●Addresses focused concerns or symptoms
●Assesses symptoms restricted to a specific body system
●Applies examination methods relevant to assessing the concern or
problem as thoroughly and carefully as possible
Tangential lighting: JVD, thyroid gland, and apical impulse of heart.
Components of the Health History Jenna/Ashley
Initial information
Identifying data and source of the history; reliability
Identifying data- age, gender, occupation, marital status
Source of history- usually patient. Can be: a family member or friend, letter of referral, or
clinical record.
Reliability- Varies according to the patient’s memory, trust, and mood.
Chief Complaint
, Chief Complaint- Make every attempt to quote the patient’s own words.
Present Illness
Complete, clear and chronological description of the problem prompting the patient visit
Onset, setting in which it occurred, manifestations and any treatments
Should include 7 attributes of a symptom:
●Location
●Quality
●Quantity or severity
●Timing, onset, duration, frequency
●Setting in which it occurs
●Aggravating or relieving factors
● Associated manifestations
-Differential diagnosis is derived from the ―pertinent positives‖ and ―pertinent negatives‖ when
doing Review of Systems that are relevant to the chief complaint. A list of potential causes for
the patients problems.
-Present illness should reveal patient’s responses to his or her symptoms and what effect this has
on their life.
-Each symptom needs its own paragraph and a full description.
-Medication should be documented, name, dose, route, and frequency. Home remedies, non-
prescriptions drugs, vitamins, minerals or herbal supplements, oral contraceptives, or borrowed
medications.
