Examination Techniques and Equipment Order of Physical Examination
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• Inspection
• Palpation
• Percussion
• Auscultation
EXCEPT Abdomen
HPI: History of Present Illness/ Problem
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, About 80% of your diagnosis will come from the historical information you
collect
Establish the problem or the CC
HPI = Symptom Analysis
Helps differentiate between possible causes Helps in ruling in or ruling out
possible causes
Patient centered care
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Defined by the Institute of Medicine as: "respecting and responding to
patients' wants, needs and preferences, so that they can make choices in
their care that best fit their individual circumstances"
Your own beliefs, attitudes, and values cannot be discarded, but you do
have to discipline them
Personal and Social History: Explore the following
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, Personal status
Habits
Self care
Sexual history
Home conditions
Occupation
Environment
Military record
Religious preference
Access to care
Interim history
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Designed to chronicle events that have occurred since your last meeting
with the patient
Substance determined by nature of problem and need of the moment
Should always be complemented by the patient's previous medical record
ROS: Head and Neck
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Headaches
Dizziness
Syncope
Head injuries
Loss of consciousness
, CC: Chief complaint/concern
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Reason for seeking Care
Always in the patients' words—this sets the focus of the visit. (may need to
teach staff!)
Should only be a couple of sentences.
"I am here for a physical exam."
"I need my cholesterol checked."
"My wife says I forget everything."
Ways to elicit CC:
• What do you want to work on today?
• What is bothering you the most today?
Note all significant complaints
Seek answer to the question
"What underlying problems or symptoms brought you here?"
Determine the duration of the current illness by asking
"How long has this problem been present?" Or
"When did these symptoms begin?"
Note age, gender, marital status, occupation, and previous hospital
admissions
Spirituality
Give this one a try later!
Give this one a try later!
• Inspection
• Palpation
• Percussion
• Auscultation
EXCEPT Abdomen
HPI: History of Present Illness/ Problem
Give this one a try later!
, About 80% of your diagnosis will come from the historical information you
collect
Establish the problem or the CC
HPI = Symptom Analysis
Helps differentiate between possible causes Helps in ruling in or ruling out
possible causes
Patient centered care
Give this one a try later!
Defined by the Institute of Medicine as: "respecting and responding to
patients' wants, needs and preferences, so that they can make choices in
their care that best fit their individual circumstances"
Your own beliefs, attitudes, and values cannot be discarded, but you do
have to discipline them
Personal and Social History: Explore the following
Give this one a try later!
, Personal status
Habits
Self care
Sexual history
Home conditions
Occupation
Environment
Military record
Religious preference
Access to care
Interim history
Give this one a try later!
Designed to chronicle events that have occurred since your last meeting
with the patient
Substance determined by nature of problem and need of the moment
Should always be complemented by the patient's previous medical record
ROS: Head and Neck
Give this one a try later!
Headaches
Dizziness
Syncope
Head injuries
Loss of consciousness
, CC: Chief complaint/concern
Give this one a try later!
Reason for seeking Care
Always in the patients' words—this sets the focus of the visit. (may need to
teach staff!)
Should only be a couple of sentences.
"I am here for a physical exam."
"I need my cholesterol checked."
"My wife says I forget everything."
Ways to elicit CC:
• What do you want to work on today?
• What is bothering you the most today?
Note all significant complaints
Seek answer to the question
"What underlying problems or symptoms brought you here?"
Determine the duration of the current illness by asking
"How long has this problem been present?" Or
"When did these symptoms begin?"
Note age, gender, marital status, occupation, and previous hospital
admissions
Spirituality
Give this one a try later!
