Class 1 Flashcards
What does comprehensive assessment provide?
Fundamental and personalized knowledge about the patient
Strengthens clinician-patient relationship
Helps identify or rule out physical causes related to patient concerns
Provides baseline for future assessments
Creates platform for health promotion through education and counseling
Develops proficiency in the essential skills of physical examination
Focused Assessment
Addresses focused concerns or symptoms
Assesses symptoms restricted to a specific body system
Applies exam methods relevant to assessing the concern or problem as precisely and carefully as possible
In out-patient clinical practice- used for most patient encounters
Routine Assessment
Should be performed annually in adults and more frequently in young children
- review of previous comprehensive history
- perform full physical examination
- consider screening exams
Types of screening exams
Testicular, rectal, breast, pelvic/PAP, etc.
Two types of H&P data collection
subjective: patient brings it (even if it’s labs ordered by someone else)
objective: you order or assess it
Benefits of Comprehensive Health History
One of most important skills
Get to know the patient and their health and social concerns
Gains their respect and trust
Allows you to formulate a good differential diagnosis
7 components of every comprehensive history
Identifying data/source of history
Chief complaint (CC)
History of present illness (HPI)
Past Medical History (PMH)
Family history (FH)
Social history (SH)
Review of systems (ROS)
Identifying data and source of history
identifying demographics (name, gender, sex assigned at birth, MRN, DOB, race if important)
source of history (patient, fam member, friend, police, EMS, medical records)
reliability of info (according to memory, honesty, and mood)
Chief complaint
Patients words on why seeking care
(whether with or w/o complaint)
*always put in quotes what they say here unless don’t have a problem
History of present illness: how
Where document/tell the patient’s history
- documented in paragraph form
- chronological order
- subjective info only
- be succinct
- only approved medical abbreviations
Differential diagnosis
List of diseases you comprise based on what the patient tells you, that are potential things that could cause the symptoms
History of present illness: documenting
Open the HPI w/patient identifiers and if historian is someone other than the patient
*also include anything discovered in other areas that is pertinent to the CC
History of present illness: 7 parameters of chief complaint/symptom
Mnemonic: “LOCATES”
Location
Onset
Character
Factors/Symptoms
Timing
Environment
Severity
Location
HPI: mnemonics
OPQRST: onset, precipitating and palliating factors, quality, region or radiation, severity, timing or temporal
OLD CARTS: onset, location, duration, character, aggravating/alleviating factors, radiation, timing, setting
Location: questions to ask
where is it?
does it radiate?
Personal and Social History
How much, when, ever tried to quit?
ask about other things as pertinent
Personal and social history CONT.
Safety Measures: pediatric/geriatric screenings… (guns, where keep drugs…)
