PHYSICAL EXAMINATION CHAPTER 30 MOD 2 ACTUAL
QUESTIONS AND ANSWERS
chief complaint: - CORRECT ANSWER✅✅A statement in the patient's own words that describes the
reason for the visit.
holistic: - CORRECT ANSWER✅✅Considering the patient as a whole; includes the physical, emotional,
social, economic, and spiritual needs of the person.
differential diagnosis - CORRECT ANSWER✅✅Considers which one of several diseases may be
producing the patient's symptoms. The possible causes for a set of symptoms are considered in order to
arrive at a diagnosis. A differential diagnosis is based on information gathered from the patient about
symptoms; contributing family, personal, and social histories; and a complete physical examination.
clinical diagnosis - CORRECT ANSWER✅✅The clinical diagnosis is arrived at after taking a detailed
history and doing a comprehensive physical examination, but before any laboratory tests or x-rays,
diagnostic testing is done.
Collecting the History Information - CORRECT ANSWER✅✅The documentation should include the
following:
• Purpose of the patient's visit, written as the chief complaint (CC)
• Patient's vital signs (VS)
• Height and weight
• Pain; documented using a scale of 1 to 10, with 1 being the least amount of pain and 10 being the
greatest amount. In some facilities, the provider takes the medical history during the patient's initial
visit.
Components of the Medical History - CORRECT ANSWER✅✅Database, Chief complaint (CC), History of
present illness (HPI), Past history (PH) or past medical history (PMH), Family history (FH), Social history
(SH), Systems review (SR) or review of systems (ROS).
Database - CORRECT ANSWER✅✅The record of the patient's demographic information along with
history, physical examination, and initial laboratory findings. As new information is added, it becomes
part of this database.
,Chief complaint (CC) - CORRECT ANSWER✅✅The purpose of the patient's visit. Generally, this is
documented in the patient's own words.
History of present illness (HPI) - CORRECT ANSWER✅✅The medical assistant should gather as much
information about the health problem as possible and document it concisely in chronologic order.
Describes the signs and symptoms from the time of onset.
Past history (PH) or past medical history (PMH) - CORRECT ANSWER✅✅A summary of the patient's
previous health. It includes dates and details about the patient:
• Usual childhood diseases (UCD or UCHD)
• Major illnesses
• Surgeries
• Allergies
• Accidents
• Immunization record
Family history (FH) - CORRECT ANSWER✅✅Details about the patient's parents and siblings and their
health; if they are deceased, the age and cause of death. This information is important because certain
diseases and disorders have familial or hereditary tendencies.
Social history (SH) - CORRECT ANSWER✅✅This section includes information about the patient's
lifestyle:
• Whether he or she feels safe at home
• Use of tobacco, alcohol, or recreational drugs
• Sleeping and exercise habits
• Typical diet
• Education and occupation
• Dental care history
, • For female patients, their last menstrual period (LMP), pregnancy history, and method of birth control
if sexually active.
Systems review (SR) or review of systems (ROS) - CORRECT ANSWER✅✅A systems review is obtained
through a logical sequence of questions about the state of health of body systems, beginning with the
head and proceeding downward. The provider typically completes this section of the medical history
while conducting the physical examination.
Allergy Documentation - CORRECT ANSWER✅✅Each medical practice has a policy on how to document
a patient's allergies. In a paper record, they typically are written in red ink or identified by a colored
sticker so that all healthcare workers can easily see it. EHR systems have methods for including allergy
information on all pertinent screens in the patient's record.
Understanding and Communicating With Patients - CORRECT ANSWER✅✅A medical assistant must
always remember that each patient is an individual with certain anxieties. These anxieties often cause
people to act and react in different ways; therefore effective verbal and nonverbal communication with
each patient is essential. A medical assistant can bring out either a positive or a negative response
simply by the way he or she treats and interacts with patients. You are usually the first person with
whom the patient communicates; therefore you play a vital role in therapeutic patient interactions.
Self-Boundaries - CORRECT ANSWER✅✅Patients may feel that they cannot share important health-
related information because you are their friend and it would be embarrassing to share that information
with a friend.
Self-boundaries can also be thought of as professional boundaries. You need to treat patients with
respect and keep the relationship professional. Be friendly to patients and always keep the focus on the
patient.
Empathy - CORRECT ANSWER✅✅A medical assistant who is empathetic respects the individuality of the
patient and attempts to see the person's health problem through his or her eyes. recognizes the effect
of all holistic factors on the patient's well-being. Empathetic sensitivity to diversity requires you to
examine your own values, beliefs, and actions; you cannot treat all patients with care and respect until
you first recognize and evaluate personal biases.
Sensitivity to Diverse Patient Groups - CORRECT ANSWER✅✅Value systems begin as learned beliefs and
behaviors. Families and cultural influences shape the way we respond to a diverse society. Other factors
that influence reactions include socioeconomic and educational backgrounds.Preconceived ideas about
QUESTIONS AND ANSWERS
chief complaint: - CORRECT ANSWER✅✅A statement in the patient's own words that describes the
reason for the visit.
holistic: - CORRECT ANSWER✅✅Considering the patient as a whole; includes the physical, emotional,
social, economic, and spiritual needs of the person.
differential diagnosis - CORRECT ANSWER✅✅Considers which one of several diseases may be
producing the patient's symptoms. The possible causes for a set of symptoms are considered in order to
arrive at a diagnosis. A differential diagnosis is based on information gathered from the patient about
symptoms; contributing family, personal, and social histories; and a complete physical examination.
clinical diagnosis - CORRECT ANSWER✅✅The clinical diagnosis is arrived at after taking a detailed
history and doing a comprehensive physical examination, but before any laboratory tests or x-rays,
diagnostic testing is done.
Collecting the History Information - CORRECT ANSWER✅✅The documentation should include the
following:
• Purpose of the patient's visit, written as the chief complaint (CC)
• Patient's vital signs (VS)
• Height and weight
• Pain; documented using a scale of 1 to 10, with 1 being the least amount of pain and 10 being the
greatest amount. In some facilities, the provider takes the medical history during the patient's initial
visit.
Components of the Medical History - CORRECT ANSWER✅✅Database, Chief complaint (CC), History of
present illness (HPI), Past history (PH) or past medical history (PMH), Family history (FH), Social history
(SH), Systems review (SR) or review of systems (ROS).
Database - CORRECT ANSWER✅✅The record of the patient's demographic information along with
history, physical examination, and initial laboratory findings. As new information is added, it becomes
part of this database.
,Chief complaint (CC) - CORRECT ANSWER✅✅The purpose of the patient's visit. Generally, this is
documented in the patient's own words.
History of present illness (HPI) - CORRECT ANSWER✅✅The medical assistant should gather as much
information about the health problem as possible and document it concisely in chronologic order.
Describes the signs and symptoms from the time of onset.
Past history (PH) or past medical history (PMH) - CORRECT ANSWER✅✅A summary of the patient's
previous health. It includes dates and details about the patient:
• Usual childhood diseases (UCD or UCHD)
• Major illnesses
• Surgeries
• Allergies
• Accidents
• Immunization record
Family history (FH) - CORRECT ANSWER✅✅Details about the patient's parents and siblings and their
health; if they are deceased, the age and cause of death. This information is important because certain
diseases and disorders have familial or hereditary tendencies.
Social history (SH) - CORRECT ANSWER✅✅This section includes information about the patient's
lifestyle:
• Whether he or she feels safe at home
• Use of tobacco, alcohol, or recreational drugs
• Sleeping and exercise habits
• Typical diet
• Education and occupation
• Dental care history
, • For female patients, their last menstrual period (LMP), pregnancy history, and method of birth control
if sexually active.
Systems review (SR) or review of systems (ROS) - CORRECT ANSWER✅✅A systems review is obtained
through a logical sequence of questions about the state of health of body systems, beginning with the
head and proceeding downward. The provider typically completes this section of the medical history
while conducting the physical examination.
Allergy Documentation - CORRECT ANSWER✅✅Each medical practice has a policy on how to document
a patient's allergies. In a paper record, they typically are written in red ink or identified by a colored
sticker so that all healthcare workers can easily see it. EHR systems have methods for including allergy
information on all pertinent screens in the patient's record.
Understanding and Communicating With Patients - CORRECT ANSWER✅✅A medical assistant must
always remember that each patient is an individual with certain anxieties. These anxieties often cause
people to act and react in different ways; therefore effective verbal and nonverbal communication with
each patient is essential. A medical assistant can bring out either a positive or a negative response
simply by the way he or she treats and interacts with patients. You are usually the first person with
whom the patient communicates; therefore you play a vital role in therapeutic patient interactions.
Self-Boundaries - CORRECT ANSWER✅✅Patients may feel that they cannot share important health-
related information because you are their friend and it would be embarrassing to share that information
with a friend.
Self-boundaries can also be thought of as professional boundaries. You need to treat patients with
respect and keep the relationship professional. Be friendly to patients and always keep the focus on the
patient.
Empathy - CORRECT ANSWER✅✅A medical assistant who is empathetic respects the individuality of the
patient and attempts to see the person's health problem through his or her eyes. recognizes the effect
of all holistic factors on the patient's well-being. Empathetic sensitivity to diversity requires you to
examine your own values, beliefs, and actions; you cannot treat all patients with care and respect until
you first recognize and evaluate personal biases.
Sensitivity to Diverse Patient Groups - CORRECT ANSWER✅✅Value systems begin as learned beliefs and
behaviors. Families and cultural influences shape the way we respond to a diverse society. Other factors
that influence reactions include socioeconomic and educational backgrounds.Preconceived ideas about
