Physical Examination Ch. 3 Flashcards
Health History (45 cards)
What is the purpose of the clinical interview in a patient encounter?
A conversation with a purpose, undertaken with a set of goals and priorities.
What are the components of the Adult Health History?
- Initial information
- Chief complaint(s)
- History of present illness
- Past medical history
- Family history
- Personal and social history
- Review of systems
What does the Chief Complaint (CC) represent?
The primary symptom or concern causing the patient to seek care.
What is the History of Present Illness (HPI)?
A concise, clear, and chronologic description of the problems prompting the patient’s visit.
What factors determine whether a patient assessment should be comprehensive or focused?
- Patient needs and concerns
- Goals for the encounter
- Clinical setting (inpatient or outpatient)
- Time available
True or False: A comprehensive patient assessment is appropriate for new patients.
True
What is subjective information in a clinical assessment?
Symptoms which are health concerns that the patient tells you.
What is objective information in a clinical assessment?
Physical examination findings or signs detected during the examination, including laboratory and diagnostic testing results.
Fill in the blank: The __________ is a source of fundamental and personalized knowledge about the patient.
comprehensive patient assessment
What does a focused patient assessment address?
Focused concerns or symptoms.
What does the ‘source of the history’ refer to?
The individual providing the history, usually the patient, but can also be a family member, caregiver, or clinical record.
What type of history includes health maintenance practices such as immunizations and lifestyle issues?
Past Medical History (PMH)
What is the role of the Review of Systems in a health history?
Documents presence or absence of common symptoms related to each of the major body systems.
What is the relevance of documenting the patient’s reliability?
It reflects the quality of the information provided by the source.
What are the attributes of a symptom that should be characterized during the HPI?
- Location
- Quality
- Quantity or severity
- Timing
- Modifying factors
- Associated manifestations
What mnemonic can help in characterizing the Chief Complaint?
OPQRST
What does ‘OPQRST’ stand for?
- Onset
- Precipitating and Palliating factors
- Quality
- Region or Radiation
- Severity
- Timing or Temporal characteristics
What is the importance of the date and time in a health history?
It is crucial, especially in urgent, emergent, or hospital settings.
What should be included in the Personal and Social History?
- Tobacco, alcohol, or recreational drug use
- Sexual history
- Educational level
- Family of origin
- Current household
- Personal interests
- Lifestyle
How should the Chief Complaint be documented?
Make every attempt to quote the patient’s own words.
What is the significance of the ‘initial information’ section in a health history?
It includes identifying data such as the patient’s initials, age, and gender.
True or False: The clinical interview should prioritize relational skills over obtaining specific information.
True
What mnemonic can help characterize the chief complaint?
OPQRST and OLD CARTS
OPQRST stands for Onset, Precipitating and Palliating factors, Quality, Region or Radiation, Severity, Timing. OLD CARTS includes Onset, Location, Duration, Character, Aggravating or Alleviating factors, Radiation, Timing, Setting.
What is the purpose of asking about additional symptoms during a clinical interview?
To generate a list of possible causes (differential diagnosis) for the patient’s problem or condition.
