Ch1 notes Flashcards
essential elements of clinical care
empathetic listening; the ability to interview patients of all ages, moods, and backgrounds; the techniques for examining the different body systems; and the process of clinical reasoning
When do you conduct a comprehensive assessment?
For all patients you are seeing for the first time
When is a focused or problem oriented assessment appropriate?
For patients you know well who are returning for routine office care or for patients with specific “urgent care” concerns
Subjective data
what the patient tells you
Objective data
what you detect during the examination
The components of comprehensive adult health history
Identifying data and source of the history/reliability; chief complaint(s); family history; present illness; personal and social history; past history; review of systems
identifying data
age, gender, occupation, marital status
source of history
usually the patient, but can be a family member or friend, letter of referral, or the medical record
reliability
varies according to the patient’s memory, trust, and mood
chief complaint(s)
the one or more symptoms of concerns causing the patient to seek care
present illness
amplifies the chief complaint; describes how each symptom developed. It includes the patient’s thoughts about the illness and pulls in relevant portions from the review of system. It may include medications, allergies, and habits of smoking and alcohol.
past history
lists childhood illnesses; lists adult illnesses with dates for at least four categories (medical, surgical, obstetric/gynecologic, and psychiatric); includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety
family history
outlines or diagrams age and health or age and cause of death of siblings, parents, and grandparents; documents presence or absence of specific illnesses in family, such as hypertension or coronary artery disease
personal and social history
describes education level, family of origin, current household, personal interests, and lifestyle
review of systems
documents presence of absence of common symptoms related to each major body system
seven attributes of a symptom
location, quality, quantity or severity, timing (onset/duration/frequency), the setting in which it occurs, factors that have aggregated or relieved the symptom, and associated manifestations
medical illnesses in past history
diabetes, hypertension, hepatitis, asthma, and HIV; hospitalizations; number and gender of sexual partners; and risky sexual practices
childhood illnesses in past history
measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, scarlet fever, polio, and chronic illnesses
surgical information in past history
dates, indications, and types of operations
obstetric/gynecologic in past history
obstetric history, menstrual history, methods of contraception, and sexual function
psychiatric information in past history
illness and time frame, diagnoses, hospitalizations, and treatments
family history questions
ask about hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies; ask about any history of cancer; ask about genetically transmitted diseases
tangential lighting
tangential lighting is optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart. It makes contours, elevations, and depressions more obvious.
Organize your assessment around three goals
maximize the patient’s comfort, avoid unnecessary changes in position, enhance clinical efficacy
