bates guide to physical exam and history
taking |Latest Exam Preparations2026|
What is a Comprehensive Health History (CHH) and when is it best used? - answers A
comprehensive interview to gather all aspects of the patient's history
For use with a new patient
What is a Focused History and when is it best used? - answers A problem-orientated
history that is more limited and tailored to a specific problem
For use with an established patient
What are the five steps of the nursing process? - answers 1. Assessment
2. Outcome Identification
3. Planning
4. Implementation
5. Evaluation
In a successful interview you... - answers 1. generate the patient's story and gather
complete and accurate data about the patient
2. Establish rapport and trust
3. Build a continuing therapeutic relationship
4. Teach about the health state, health promotion and disease prevention.
What is patient centered care?
(Institute of Medicine definition) - answers Respecting and responding to patients'
wants, needs, and preferences, so they can make choices in their care that best fit their
individual circumstances.
Setting the Environment for a patient interview - what is important? - answers Courtesy
and Comfort
1. Privacy - Knock on the door, use privacy curtains, be aware of room-mates (inquire
about confidentiality wishes)
2. Attention/lack of interruptions - ask for coverage help to ensure you give the patient
your full attention
3. Comfortable room - make sure room is clean and at adequate temperature
4. Seating - provide comfortable seating for the patient, sit at equal level with the
patient, do not place furniture between you and the patient.
5. Dress - Understand and be empathetic to patient vulnerability in gowns. Wear proper
uniform (provides patient with professional image and establishes non-verbal
recognition of care).
,6. Note taking/use of computer during the interview at minimum - explain why you are
taking notes or using a computer, involve patient if possible.
What is involved in effective communication for skilled interviewing? - answers 1. Active
Listening
2. Empathetic responses - non-verbal and verbal, be open and genuine, pay attention to
patient body language and cues
3. Guided questioning - ask open-ended questions, pause between questions, give
multiple choices if needed
4. Non-verbal communication - maintain professionalism in all patient answers
5. Validation & Reassurance - do not say "you will be ok" and avoid false reassurance
6. Partnering - let the patient know we are not going to abandon them
7. Summarize - gives clarity to the interaction, allows patient to provide input if anything
is inaccurate or missing.
8. Use transitions
9. Empowering the patient - ask what the patient wants, goals
What does OLDCARTS stand for? - answers O - onset
L - Location
D - Duration
C - Character
A - Aggrivating/Alleviating Factors
R - Radiation
T - Timing
S - summary
What does OPQRST stand for? - answers O - Onset
P - Palliating/Provoking Factors
Q - Quality
R - Radiating
S - Site
T - Timing
What are the seven attributes of a symptom - answers 1. Location - where is it? does it
radiate?
2. Quality - what is it like?
3. Quantity or severity - how bad is it? (for pain, 1-10 raiting)
4. Timing - when did (does) it start? How long does it last? How often does it come?
5. Setting in which it occurs - include environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the illness
6. Remitting or exacerbating factors - is there anything that makes it better or worse?
7. Associated manifestations - have you noticed anything else that accompanies it?
Exploring the patients perspective - understand what are the patients... - answers 1.
Feelings about the problem
2. Ideas about the nature and cause of the problem
,3. Functional changes and effect on the patient's life
4. Expectations of the disease, clinician, or of health care.
Responding to a patients emotions - you... - answers 1. Name the emotion (it appears
to me that...)
2. Understand
3. Respect
4. Support - offer services if possible
5. Explore - ask what the patient wants to do...
What non-verbal cues to you look for when interviewing a patient? - answers 1. Physical
appearance - clothes, posture
2. Formal vs. informal - always start formal, determine patients desired level of formality
3. Gestures - be aware of different cultural meanings
4. Eye contact - be aware of different cultural meanings
5. Voice - tone, level
6. Touch - therapeutic touch
Tips for approaching sensitive topics (sex, drugs, violence, death, mental illness) -
answers 1. Be non-judgmental
2. Explain why you need to know certain information
3. Use opening questions for sensitive topics
4. Be aware of your own discomfort - the patient will pick up on non-verbal cues.
Traps to avoid in healthcare... - answers 1. Giving false reassurance
2. Giving unwanted advice
3. Using authority - only appropriate in certain circumstances
4. Avoidance language and distancing
5. Leading questions
6. Talking too much
7. Interrupting
8. "why"
9. Overuse of professional terminology
Barriers to interviewing a patient - answers 1. Patients curiosity about you - shifting the
conversation away from themselves
2. Anxiety - can alter examination findings
3. Silence
4. Depression
5. Crying
6. Seduction
7. Anger
8. Avoiding the full story
9. Finances - not all can afford tests/procedures
10. Language differences - use an interpretor if at all possible
11. Literacy - speak to the patient in terms they will understand.
, What is subjective data? - answers What the person says about him/herself
What is objective data? - answers What you observe through measurement, inspection,
palpation, percussion and auscultation. Physical examination findings. Laboratory
results. Diagnostic tests.
How to structure a Health History - answers 1. Identifiers
2. Chief Complaint (CC)
3. History of Present Illness (HPI)
4. Past Medical History (PMH)
5. Family History (FH)
6. Personal and Social History (SH)
7 .Review of Symptoms (ROS)
What is the chief complaint? (CC) - answers The reason the patient is seeking care.
Give a brief statement using the patients own words.
What is one of the most important things to ask a patient as soon as they present for
care? (or look for in their chart?) - answers Allergies/Medications
Do they have any allergies?
What medications are they taking?
What is included in a past medical history (PMH)? - answers 1. General state of health
2. Hospitalizations
3. Childhood illnesses
4. Major adult illnesses
5. Serious accidents/injuries
6. Medical/Surgical/Obstetric and Gynecologic/Psychiatric
7. Health maintenance (immunizations, medications (past/present/recent)
8. Allergies
9. Transfusions (reason, reaction?)
10. Recent lab tests and screening exams
What is included in the Family Health History and where is it found? - answers Found in
a comprehensive health history. Includes genetically linked potential health risks for 3
generations.
Make sure to document both positive and negative findings.
What is included in social history? - answers 1. Cultural background/personal status
2. Sources of stress
3. Health beliefs
4. Habits (exercise, nutrition, caffeine, obesity/weight control, self-care, safety
measures)
5. Tobacco use
taking |Latest Exam Preparations2026|
What is a Comprehensive Health History (CHH) and when is it best used? - answers A
comprehensive interview to gather all aspects of the patient's history
For use with a new patient
What is a Focused History and when is it best used? - answers A problem-orientated
history that is more limited and tailored to a specific problem
For use with an established patient
What are the five steps of the nursing process? - answers 1. Assessment
2. Outcome Identification
3. Planning
4. Implementation
5. Evaluation
In a successful interview you... - answers 1. generate the patient's story and gather
complete and accurate data about the patient
2. Establish rapport and trust
3. Build a continuing therapeutic relationship
4. Teach about the health state, health promotion and disease prevention.
What is patient centered care?
(Institute of Medicine definition) - answers Respecting and responding to patients'
wants, needs, and preferences, so they can make choices in their care that best fit their
individual circumstances.
Setting the Environment for a patient interview - what is important? - answers Courtesy
and Comfort
1. Privacy - Knock on the door, use privacy curtains, be aware of room-mates (inquire
about confidentiality wishes)
2. Attention/lack of interruptions - ask for coverage help to ensure you give the patient
your full attention
3. Comfortable room - make sure room is clean and at adequate temperature
4. Seating - provide comfortable seating for the patient, sit at equal level with the
patient, do not place furniture between you and the patient.
5. Dress - Understand and be empathetic to patient vulnerability in gowns. Wear proper
uniform (provides patient with professional image and establishes non-verbal
recognition of care).
,6. Note taking/use of computer during the interview at minimum - explain why you are
taking notes or using a computer, involve patient if possible.
What is involved in effective communication for skilled interviewing? - answers 1. Active
Listening
2. Empathetic responses - non-verbal and verbal, be open and genuine, pay attention to
patient body language and cues
3. Guided questioning - ask open-ended questions, pause between questions, give
multiple choices if needed
4. Non-verbal communication - maintain professionalism in all patient answers
5. Validation & Reassurance - do not say "you will be ok" and avoid false reassurance
6. Partnering - let the patient know we are not going to abandon them
7. Summarize - gives clarity to the interaction, allows patient to provide input if anything
is inaccurate or missing.
8. Use transitions
9. Empowering the patient - ask what the patient wants, goals
What does OLDCARTS stand for? - answers O - onset
L - Location
D - Duration
C - Character
A - Aggrivating/Alleviating Factors
R - Radiation
T - Timing
S - summary
What does OPQRST stand for? - answers O - Onset
P - Palliating/Provoking Factors
Q - Quality
R - Radiating
S - Site
T - Timing
What are the seven attributes of a symptom - answers 1. Location - where is it? does it
radiate?
2. Quality - what is it like?
3. Quantity or severity - how bad is it? (for pain, 1-10 raiting)
4. Timing - when did (does) it start? How long does it last? How often does it come?
5. Setting in which it occurs - include environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the illness
6. Remitting or exacerbating factors - is there anything that makes it better or worse?
7. Associated manifestations - have you noticed anything else that accompanies it?
Exploring the patients perspective - understand what are the patients... - answers 1.
Feelings about the problem
2. Ideas about the nature and cause of the problem
,3. Functional changes and effect on the patient's life
4. Expectations of the disease, clinician, or of health care.
Responding to a patients emotions - you... - answers 1. Name the emotion (it appears
to me that...)
2. Understand
3. Respect
4. Support - offer services if possible
5. Explore - ask what the patient wants to do...
What non-verbal cues to you look for when interviewing a patient? - answers 1. Physical
appearance - clothes, posture
2. Formal vs. informal - always start formal, determine patients desired level of formality
3. Gestures - be aware of different cultural meanings
4. Eye contact - be aware of different cultural meanings
5. Voice - tone, level
6. Touch - therapeutic touch
Tips for approaching sensitive topics (sex, drugs, violence, death, mental illness) -
answers 1. Be non-judgmental
2. Explain why you need to know certain information
3. Use opening questions for sensitive topics
4. Be aware of your own discomfort - the patient will pick up on non-verbal cues.
Traps to avoid in healthcare... - answers 1. Giving false reassurance
2. Giving unwanted advice
3. Using authority - only appropriate in certain circumstances
4. Avoidance language and distancing
5. Leading questions
6. Talking too much
7. Interrupting
8. "why"
9. Overuse of professional terminology
Barriers to interviewing a patient - answers 1. Patients curiosity about you - shifting the
conversation away from themselves
2. Anxiety - can alter examination findings
3. Silence
4. Depression
5. Crying
6. Seduction
7. Anger
8. Avoiding the full story
9. Finances - not all can afford tests/procedures
10. Language differences - use an interpretor if at all possible
11. Literacy - speak to the patient in terms they will understand.
, What is subjective data? - answers What the person says about him/herself
What is objective data? - answers What you observe through measurement, inspection,
palpation, percussion and auscultation. Physical examination findings. Laboratory
results. Diagnostic tests.
How to structure a Health History - answers 1. Identifiers
2. Chief Complaint (CC)
3. History of Present Illness (HPI)
4. Past Medical History (PMH)
5. Family History (FH)
6. Personal and Social History (SH)
7 .Review of Symptoms (ROS)
What is the chief complaint? (CC) - answers The reason the patient is seeking care.
Give a brief statement using the patients own words.
What is one of the most important things to ask a patient as soon as they present for
care? (or look for in their chart?) - answers Allergies/Medications
Do they have any allergies?
What medications are they taking?
What is included in a past medical history (PMH)? - answers 1. General state of health
2. Hospitalizations
3. Childhood illnesses
4. Major adult illnesses
5. Serious accidents/injuries
6. Medical/Surgical/Obstetric and Gynecologic/Psychiatric
7. Health maintenance (immunizations, medications (past/present/recent)
8. Allergies
9. Transfusions (reason, reaction?)
10. Recent lab tests and screening exams
What is included in the Family Health History and where is it found? - answers Found in
a comprehensive health history. Includes genetically linked potential health risks for 3
generations.
Make sure to document both positive and negative findings.
What is included in social history? - answers 1. Cultural background/personal status
2. Sources of stress
3. Health beliefs
4. Habits (exercise, nutrition, caffeine, obesity/weight control, self-care, safety
measures)
5. Tobacco use
