PHYSICAL EXAMINATION CHAPTER 30 MOD 2 UPDATED
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
1. chief complaint:
Answer:
A statement in the patient's own words that describes the reason for the visit.
Question:
2. holistic:
Answer:
Considering the patient as a whole; includes the physical, emotional, social, economic, and spiritual needs
of the person.
Question:
3. differential diagnosis
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.
Question:
4. clinical diagnosis
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.
Question:
5. Collecting the History Information
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.
Question:
6. Components of the Medical History
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).
,Question:
7. Database
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.
Question:
8. Chief complaint (CC)
Answer:
The purpose of the patient's visit. Generally, this is documented in the patient's own words.
Question:
9. History of present illness (HPI)
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.
Question:
10. Past history (PH) or past medical history (PMH)
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
Question:
11. Family history (FH)
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.
Question:
12. Social history (SH)
, 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.
Question:
13. Systems review (SR) or review of systems (ROS)
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.
Question:
14. Allergy Documentation
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.
Question:
15. Understanding and Communicating With Patients
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.
Question:
16. Self-Boundaries
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.
Question:
17. Empathy
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
1. chief complaint:
Answer:
A statement in the patient's own words that describes the reason for the visit.
Question:
2. holistic:
Answer:
Considering the patient as a whole; includes the physical, emotional, social, economic, and spiritual needs
of the person.
Question:
3. differential diagnosis
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.
Question:
4. clinical diagnosis
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.
Question:
5. Collecting the History Information
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.
Question:
6. Components of the Medical History
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).
,Question:
7. Database
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.
Question:
8. Chief complaint (CC)
Answer:
The purpose of the patient's visit. Generally, this is documented in the patient's own words.
Question:
9. History of present illness (HPI)
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.
Question:
10. Past history (PH) or past medical history (PMH)
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
Question:
11. Family history (FH)
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.
Question:
12. Social history (SH)
, 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.
Question:
13. Systems review (SR) or review of systems (ROS)
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.
Question:
14. Allergy Documentation
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.
Question:
15. Understanding and Communicating With Patients
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.
Question:
16. Self-Boundaries
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.
Question:
17. Empathy
