A 57-year-old maintenance worker comes to your office for evaluation of pain in
his legs. He has smoked two packs per day since the age of 16, but he is
otherwise healthy. You are concerned that he may have peripheral vascular
disease. Which symptom is concerning?
~ Intermittent claudicatio...
-Used for established clients during routine or urgent care visits
-Health history and physical exams are focused on the problem
-Includes:
• brief history of the present illness
• only the system related to the problem in the review of systems
Comprehensive Assessment
✓~ -Used for new clients
-Provides personalized information about the client
-Strengthens the clinician-client relationship
-Provides a baseline for future assessments
-Provides an opportunity for health promotion education and counseling
,-Includes:
• extended history of the present illness
• at least two areas of past medical history, family history, and social history
• at least 10 systems in the review of systems
Subjective data
✓~ includes symptoms that the client describes such as a sore throat,
headache, or pain. It also includes the client's feelings, perceptions, and
concerns
Information obtained from the client during any part of the health history
Examples of Subjective Data:
-Lower back pain
-Fatigue
-Stomach cramps
-Immunization history
Objective data
,✓~ includes the physical examination findings or signs observed
All physical examinations, laboratory information, and test data
Examples of Objective Data:
-Heart rate
-Blood pressure
-Lung sounds
-Wound appearance
-Ambulation description
-Weight
Clinical Encounter Sequence (detailed)
✓~ Initiate Encounter
-Review the clinical record
-Ensure the client is comfortable
-Clarify the goals/agenda for the encounter; balance provider and client goals
-Establish rapport
-Identify the client's preferred title, name, and gender pronouns
, -Use "people first" language (i.e., a person with hearing loss, a person who uses a
wheelchair)
Gather Information
-ID the client's chief complaint or reason for seeking care
-Invite the client's story using an open-ended approach
-Gather information about the client's perspective of the illness using the
mnemonic FIFE
-Conduct the health history interview
-Gather information about past medical history, medications and allergies,
family history, personal and social history, and ROS
Perform the Physical Exam
-Conduct the exam based on the information obtained from the health history
-Maintain client's comfort and privacy throughout the exam
Explain and Plan
-Assess and respond to the client's needs for information
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