Patient History and Examination

Question 1

What is the Medical Process?

Answer 1

1. Patient Contact
2. Patient History
3. Physical Exam
4. Plan

Question 2

What is part of the Plan in the medical process?

Answer 2

1. case summary
2. plan for work-up
3. management
4. follow up

Question 3

What is important about patient contact?

Answer 3

• active listening
• it is all about the setting of the interview
• we want it comfortable
• need to be able to explain what is happening
• might need to set a time limit and stick to what is important
• nice to have relative for a support system present to make sure information is absorbed
• consider if a translator is needed

Question 4

Describe the process of Patient History

Answer 4

this is important and is when you find out important information on the patient.

1. introduction (age, gender reason for admission)
2. allergies
3. dispositions
4. exposition
5. past medical history
6. present medical history
7. other organ systems
8. medications
9. alcohol/tobacco/drugs
10. social and family history

Question 5

dispositions

Answer 5

1. Hereditary diseases (i.e. diabetes, hypertension, blood clots, cancer)
2. Genetic disorders
3. Similar cases in family
4. Recent surgery

Question 6

expositions

Answer 6

• More about what’s been going on
• Environmental (home, work, substance abuse)
• Contagious, sexual, travel

Question 7

what does present medical history refer to?

Answer 7

• this will usually be covered first (in the patients own words)
• What is the patient experiencing?/Why have they sought medical help?
• TINA
• “B-symptoms”
• Can indicate underlying malignant disease

Question 8

B symptoms

Answer 8

• fever
• night sweats
• weight loss (how much/long?) (Intended/unintended)
• should ask about menopause because that can also cause these

Question 9

TINA

Answer 9

(Timing, Influences, Nature, Associations) in regards to the problem

Question 10

Explain an example of Pain of present medical history

Answer 10

Pain:
• Location: Wandering/radiation
• Character (burning, stabbing, throbbing, constant, returning)
• Relieving and aggravating factors: Pain killers.
• Intensity: Numerical range Scale (NRS) or Visual analog scale (VAS):
• “on a scale from 0 to 10 where 0 is ‘no pain at all’ and 10 is ‘worst pain ever’,
where would you place your pain?”

Question 11

Other organ systems

Answer 11

• CNS
• cardio/pulmonary
• gastro intestinal
• gynocology
• locomotor system

Question 12

What three factors should be included when thinking about the social aspects of peoples lives:

Answer 12

• biological: age/gender/tissue health
• Psychological :mental/emotional/expectations
• sociological: interpersonal relationships/social support