Comprehensive Assseessment
- new patients
- fundamental/personalized knowledge about pt
- strengthens relationship
- ID/rule out physical causes r/t pt conerns
- baseline
- platform for health education
- proficiency in essential skills of physical exam
Focused Assessment
- established pts (routine or urgent care)
- focused concerns/symptoms
- address symptoms r/t body system
- exam methods relevant to concern throughly and carefully
Subjective Data
- what pt tells you
- symptoms and history (chief complaint and review of symptoms)
Objective Data
- what you detect during exam, labs, tests
- all physical exam findings or signs
components of comprehensive health history
- identifying data and source of history; reliability
- chief complaint
- present illness
- past history
- family history
- personal and social history
- review of symptoms
Identifying Data
age, gender, occupation, marital status
source of history/referral (usually pt or family member)
Reliability
varies by pt memory, trust, mood
vague, confusing, reliable
Chief complaint
one or ore symptoms or concerns causing pt to seek care
use quotes
Present Illness
amplifies chief complaint, describes how each symptom develops
includes pts thoughts about illness
pulls in relevant portions of review of symptoms (pertinent positives and negatives)
may include medications, allergies, tobacco use, alcohol if pertinent to present illness
Past History
childhoods illnesses adult illnesses (medical, surgical, OB/GYN, psych) health maintenance (immunizations, screenings, lifestyle, home safety)
Family History
age & health/cause of death of siblings, parents, grandparents
presence of absence of specific diseases (HTN, DM, CA)
Personal/Social History
educational level, job family of origin current household personal interests (religion) lifestyle (exercise, diet, sexual orientation)
Review of Symptoms
presence or absence of common symptoms related to each of the major body systems
7 attributes of physical symptoms
Location Quality Quantity or Severity Timing (Onset, duration, frequency) Setting in which it occurs Factors aggravating/alleviating Associated Manifestations
Palpation
tactile pressure from palmar fingers or fingerpads
Percussion
use of the striking or plexor finger, usually the 3rd, to deliver a rapid tap or blow against the distal pleximeter finger, usually dial 3rd finger of the left hand laid against a body surface
recommended patient side for physical exam
patient’s right side
Head to Toe Exam
- general survey
- vital signs
- skin
- HEENT
- neck
- back
- posterior thorax/lungs
- breasts/axillae, epitrochlear nodes
- musculoskeletal throughout or here if needed*
- anterior thorax and lungs
- cardiovascular
- abdomen
- lower extremities
- nervous system
- additional exams (rectal/genital)
steps to ID problems and make diagnoses
- ID abnormal findings
- localize findings anatomically
- cluster clinical findings
- search for probable cause of findings
- cluster clinical data
- generate hypotheses about causes of pt problems
- test hypotheses and establish working diagnosis
helpful clinical characteristics to cluster clinical findings
- pt age (younger - 1 disease, older - multiple)
- timing of symptoms (related or unrelated)
- involvement of different body systems (1 disease may explain)
- multisymptom conditions (explore risk factors)
key questions (steers thinking)
steps for generating clinical hypotheses
- select more specific and critical findings to support your hypothesis
- match your findings against all conditions that can produce them
- eliminate diagnostic possibilities that fails to explain findings
- weigh competing possibilities and select most likely diagnosis
- give special attention to potentially life threatening conditions
Problem List
list most active and serious problems first w/ date on onset (can have active vs. inactive lists)
