Advanced Health Assessment and Diagnostic Reasoning #1
1. Describe the differences between
a. A comprehensive health history/exam
Includes all the elements of the health history and the complete physical examination.
- Provides fundamental and personalized knowledge about the patient
- Strengthens the clinician-patient relationship
- Helps identify or rule out physical causes related to patient concerns
Provides a baseline for future assessments
-Creates a platform for health promotion through education and counseling
- Develops proficiency in the essential skills of physical examination
b. A focused health history/exam
Assesses symptoms restricted to a specific body system (eg. sore throat or knee pain)
Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as
possible
The patient's symptoms, age, and health history help determine the scope of the focused examination, as does
your knowledge of disease pattern
2. Identify examples of when you would obtain (2 examples for each):
a. A comprehensive health history/exam
Is appropriate for new patients in the office or hospital
b. A focused health history/exam
Is appropriate for established patients, especially during routine or urgent care visits
Addresses focused concerns or symptoms
( eg. sore throat or knee pain)
3. Discuss the differences between subjective and objective data
Subjective data: is what the patient tells you
Objective data: what you detect during the examination, laboratory information and test data
a. Provide examples of what would constitute Subjective data
The symptoms and history, from Chief Complaint through Review of Systems
Example: Mrs. G. is a 54-year-old hairdresser who reports pressure over her left chest "like an elephant sitting
there," which goes into her left neck and arm.
b. Provide examples of what would constitute Objective data
All physical examination findings, or signs
Example: Mrs. G. is an older, overweight white female, who is pleasant and cooperative. Height 5′4′′, weight 150
lbs, BMI 26, BP 160/80, HR 96 and regular, respiratory rate 24, temperature 97.5 °F
, 4. Identify what goes into each section of the comprehensive health history
a. Identifying data and source of history
Identifying data—such as age, gender, occupation, marital status
Source of the history—usually the patient, but can be a family member or friend, letter of referral, or the clinical
record
If appropriate, establish the source of referral, because a written report may be needed
b. Chief complaint
The one or more symptoms or concerns causing the patient to seek care.
Note: make every attempt to quote the pt's own words. Eg. "my stomach hurts and I feel awful"
c. History of present illness
Is a complete, clear, and chronologic description of the problems prompting the patient's visit, including the onset
of the problem, the setting in which it developed, its manifestations, and any treatments to date.
Pulls in relevant portions of the Review of Systems, called "pertinent positives and negatives" (see p. 11)
May include medications, allergies, and tobacco use and alcohol, which are frequently pertinent to the present
illness
d Past history
Lists childhood illnesses
Lists adult illnesses with dates for events in at least four categories: medical, surgical, ob/gyn, & psychiatric
Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety
e. Family history
Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents
Documents presence or absence of specific illnesses in family, such as hypertension, diabetes, or type of cancer
f. Personal and social history
- Describes educational level, family of origin, current household, personal interests, and lifestyle.
- occupation & health promotion
- hx of tobacco, drug & alcohol use.
(Health Promotion/Maintenance Activities: screenings, immunizations, sleep, exercise
Tobacco Use: (never, quit, or current; amount) [Type - ie. cigarette, e-cigarette, smokeless tobacco, etc.)
Alcohol and Drug use: (never, quit, current; type)).
g. Review of systems
Documents presence or absence of common symptoms related to each of the major body systems
Bonus : Cardinal techniques of Examination
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
