Foundations for clinical proficiency

Question 1

Identifying data

Answer 1

age, gender, occupation, marital status, source of history

Question 2

chief complaint

Answer 2

one or more symptoms or concerns causing the patient to seek care, quote the patient’s own words

Question 3

present illness

Answer 3

amplifies the chief complaint, describes how each symptom developed; includes patient’s thoughts and feelings about the illness, pulls in relevant portions of ROS, called “pertinent positives and negatives”

Question 4

past history

Answer 4

list childhood illness, list adult illness from 4 categories (medical, surgical, OB/GYN, psychiatric)

Question 5

family history

Answer 5

outlines or diagrams age and health or age and cause of death, document presence or absence of specific illness in the family such as hypertension, diabetes, or type of cancer

Question 6

personal and social history

Answer 6

educational level, a family of origin, current household, personal interests, and lifestyle

Question 7

review of symptoms

Answer 7

presence or absence of common symptoms related to each of the major body systems

Question 8

7 attributes of a symptom

Answer 8

1. Location
2. Quality
3. Quantity or severity
4. timing, including onset, duration and frequency
5. the setting in which it occurs
6. factors that have aggravated or relieved the symptom
7. Associated manifestations

Question 9

Techniques of examination

Answer 9

inspection
palpation
percussion
auscultation