PHYSICAL EXAMINATION AND HISTORY
TAKING COMPREHENSIVE STUDY GUIDE 2026
◉ Focused Assessment. Answer: -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 precisely and carefully as possible
◉ Subjective Data. Answer: -What the patient tells you
-The history, from Chief Complaints 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: 1. Identifying Data and Source of the History; Reliability
2. Chief Complaint(s)
3. Present Illness
4. Past History
5. Family History
,6. Personal and Social History
7. Review of Systems
◉ Identifying Data. Answer: -Identifying data - such as age, gender,
occupation, marital status
-Source of the 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
-Make every attempt to quote the patient's own words
-If no specific complaints; report their goals instead
◉ Present Illness. Answer: -Amplifies the Chief Complaint; describes
how each symptom developed (7 attributes - location, quality,
quantity or severity, timing [including onset, duration, and
frequency], setting in which it occurs, factors that have aggravated
or relieved the symptom, and associated manifestations)
-Includes patient's thoughts and feelings about the illness
, -Pulls in relevant portions of the Review of Systems, called
"pertinent positives and negatives"; these indicate the presence or
absence of symptoms relevant to the differential diagnosis, which
identifies the most likely diagnoses explaining the patient's
condition
-May include medications (name, dose, route, and frequency of use.
List home remedies, nonprescription drugs, vitamins, mineral or
herbal supplements, oral contraceptives, and medicines borrowed
from family members or friends. Ask patient to bring in all their
medications), allergies (include specific reactions to each
medications, as well as allergies to foods, insects, or environmental
factors), and habits of smoking (include the type - cigarettes are
often reported in pack-years [a person who has smoked 1 1/2 packs
a day for 12 years has an 18-pack-year history) and alcohol and drug
use, which are frequently pertinent to the present illness
◉ Past History. Answer: -List childhood illnesses (measles, rubella,
mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever,
and polio, and any chronic childhood illnesses)
-Lists adult illnesses with dates for at least four categories: medical
(diabetes, hypertension, hepatitis, asthma, and HIV; hospitalization;
number and gender of sexual partners; and risky sexual practices),
surgical (dates, indications, and types of operations),
obstetric/gynecologic (obstetric history, menstrual history, methods
of contraceptions, and sexual function), and psychiatric (illness and
time frame, diagnoses, hospitalizations, and treatments
-Includes health maintenance practices such as immunizations
(tetanus, pertussis, diptheria, polio, measles, rubella, mumps,
TAKING COMPREHENSIVE STUDY GUIDE 2026
◉ Focused Assessment. Answer: -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 precisely and carefully as possible
◉ Subjective Data. Answer: -What the patient tells you
-The history, from Chief Complaints 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: 1. Identifying Data and Source of the History; Reliability
2. Chief Complaint(s)
3. Present Illness
4. Past History
5. Family History
,6. Personal and Social History
7. Review of Systems
◉ Identifying Data. Answer: -Identifying data - such as age, gender,
occupation, marital status
-Source of the 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
-Make every attempt to quote the patient's own words
-If no specific complaints; report their goals instead
◉ Present Illness. Answer: -Amplifies the Chief Complaint; describes
how each symptom developed (7 attributes - location, quality,
quantity or severity, timing [including onset, duration, and
frequency], setting in which it occurs, factors that have aggravated
or relieved the symptom, and associated manifestations)
-Includes patient's thoughts and feelings about the illness
, -Pulls in relevant portions of the Review of Systems, called
"pertinent positives and negatives"; these indicate the presence or
absence of symptoms relevant to the differential diagnosis, which
identifies the most likely diagnoses explaining the patient's
condition
-May include medications (name, dose, route, and frequency of use.
List home remedies, nonprescription drugs, vitamins, mineral or
herbal supplements, oral contraceptives, and medicines borrowed
from family members or friends. Ask patient to bring in all their
medications), allergies (include specific reactions to each
medications, as well as allergies to foods, insects, or environmental
factors), and habits of smoking (include the type - cigarettes are
often reported in pack-years [a person who has smoked 1 1/2 packs
a day for 12 years has an 18-pack-year history) and alcohol and drug
use, which are frequently pertinent to the present illness
◉ Past History. Answer: -List childhood illnesses (measles, rubella,
mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever,
and polio, and any chronic childhood illnesses)
-Lists adult illnesses with dates for at least four categories: medical
(diabetes, hypertension, hepatitis, asthma, and HIV; hospitalization;
number and gender of sexual partners; and risky sexual practices),
surgical (dates, indications, and types of operations),
obstetric/gynecologic (obstetric history, menstrual history, methods
of contraceptions, and sexual function), and psychiatric (illness and
time frame, diagnoses, hospitalizations, and treatments
-Includes health maintenance practices such as immunizations
(tetanus, pertussis, diptheria, polio, measles, rubella, mumps,
