Clinical Assessment History & Physical Examination Test
Questions
What's a holistic summary of the diagnostic process?
1. Take a history
2. Develop hypotheses
3. Perform a Physical Examination
4. Generate a differential diagnosis
5. Test the hypotheses
6. Modify your differential diagnosis
7. Repeat steps 1 to 6
8. Make the diagnosis or diagnoses
9. If uncertain, consider a provisional diagnosis or watchful waiting
What's a holistic summary of the history?
Chief Complaints (CC)
History of Present Illness (HPI)
Medications (Meds)
Allergies
Past Medical History (PMH)
Past Surgical History (PSH)
Family History (FH)
Personal & Social History (SH)
Review of Systems (ROS)
What are some big first impressions that your patient is going to make when you first walk in the door?
Dress, Hygiene (Are you wearing sweatpants?)
Demeanor (Are you nice? Immature?)
Verbal tone/word usage (No medical jargon/swearing).
Body language/Non verbal cues (Eye contact).
Truthfulness (Don't make up something to answer a patient's question).
What is the medical history?
- Patient information, NOT clinician's interpretation
- What the patient tells us, not what we find through examination
- Symptoms vs. Signs ("My stomach really hurts" vs. "The Pt exhibited a rash around the bite."
- Details and clarification a must!
, What is the OBJECTIVE of the medical history?
- To gather information about the patient.
- To establish rapport (get them to trust you).
- Discover symptoms.
- Obtain accurate qualitative descriptions ("I'm experiencing a tearing pain in my back.")
- Secure precise chronology of events (when everything happened).
- Determine how illness changes the Pt's life; ADL affected?
- Facilitate understanding.
- Assist in Pt's management.
- Pt education regarding diagnosis, treatment, & prevention.
- Provide therapeutic outlet
- Guide physical examination
What are open-ended questions?
- Questions that have more than just a "yes or no" answer.
What are direct questions?
Those that seek specific information. Such as "How long ago did that happen?" or "Where does it hurt?"
What are leading questions?
A question which because of the way it has been phrased suggests a certain answer. "It's a sharp pain,
right?"
What is the appropriate way to interact with pediatric patients?
- Pay attention to them.
- Play with them.
- Be sensitive to their needs.
- Family dynamics.
What is the appropriate way to interact with adolescent patients?
- Respect need for confidentiality.
- Respect impending adult status.
- Don't force conversation.
- Establish an alliance.
- Be flexible in approach.
What is the best way to obtain a history from a pregnant woman?
- View health needs of mother and fetus; make sure she has a gynecologist/primary care doctor.
- Explore effects of pregnancy on health status.
- Use interview as time for teaching health care practices. Improve nutrition.
- Involve partner if possible.
What is the appropriate way to interact with elderly patients?
Questions
What's a holistic summary of the diagnostic process?
1. Take a history
2. Develop hypotheses
3. Perform a Physical Examination
4. Generate a differential diagnosis
5. Test the hypotheses
6. Modify your differential diagnosis
7. Repeat steps 1 to 6
8. Make the diagnosis or diagnoses
9. If uncertain, consider a provisional diagnosis or watchful waiting
What's a holistic summary of the history?
Chief Complaints (CC)
History of Present Illness (HPI)
Medications (Meds)
Allergies
Past Medical History (PMH)
Past Surgical History (PSH)
Family History (FH)
Personal & Social History (SH)
Review of Systems (ROS)
What are some big first impressions that your patient is going to make when you first walk in the door?
Dress, Hygiene (Are you wearing sweatpants?)
Demeanor (Are you nice? Immature?)
Verbal tone/word usage (No medical jargon/swearing).
Body language/Non verbal cues (Eye contact).
Truthfulness (Don't make up something to answer a patient's question).
What is the medical history?
- Patient information, NOT clinician's interpretation
- What the patient tells us, not what we find through examination
- Symptoms vs. Signs ("My stomach really hurts" vs. "The Pt exhibited a rash around the bite."
- Details and clarification a must!
, What is the OBJECTIVE of the medical history?
- To gather information about the patient.
- To establish rapport (get them to trust you).
- Discover symptoms.
- Obtain accurate qualitative descriptions ("I'm experiencing a tearing pain in my back.")
- Secure precise chronology of events (when everything happened).
- Determine how illness changes the Pt's life; ADL affected?
- Facilitate understanding.
- Assist in Pt's management.
- Pt education regarding diagnosis, treatment, & prevention.
- Provide therapeutic outlet
- Guide physical examination
What are open-ended questions?
- Questions that have more than just a "yes or no" answer.
What are direct questions?
Those that seek specific information. Such as "How long ago did that happen?" or "Where does it hurt?"
What are leading questions?
A question which because of the way it has been phrased suggests a certain answer. "It's a sharp pain,
right?"
What is the appropriate way to interact with pediatric patients?
- Pay attention to them.
- Play with them.
- Be sensitive to their needs.
- Family dynamics.
What is the appropriate way to interact with adolescent patients?
- Respect need for confidentiality.
- Respect impending adult status.
- Don't force conversation.
- Establish an alliance.
- Be flexible in approach.
What is the best way to obtain a history from a pregnant woman?
- View health needs of mother and fetus; make sure she has a gynecologist/primary care doctor.
- Explore effects of pregnancy on health status.
- Use interview as time for teaching health care practices. Improve nutrition.
- Involve partner if possible.
What is the appropriate way to interact with elderly patients?
