File Name: history taking and physical examination mcq .zip
Your abil- ity to gather a sensitive and nuanced history and to perform a thorough and accurate examination deepens your patient relationships, focuses your patient assessment, and sets the direction of your clinical thinking. The quality of your history and physical examination governs your next steps with the patient and guides your choices from the initially bewildering array of secondary testing and technology.
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Your abil- ity to gather a sensitive and nuanced history and to perform a thorough and accurate examination deepens your patient relationships, focuses your patient assessment, and sets the direction of your clinical thinking.
The quality of your history and physical examination governs your next steps with the patient and guides your choices from the initially bewildering array of secondary testing and technology.
Over the course of becoming an accomplished clinician, you will polish these important relational and clinical skills for a lifetime. As you enter the realm of patient assessment, you begin integrating the es- sential elements of clinical care: empathic listening; the ability to interview patients of all ages, moods, and backgrounds; the techniques for examining the different body systems; and, nally, the process of clinical reasoning.
Your experience with history taking and physical examination will grow and expand, and the steps of clinical reasoning will soon begin with the rst moments of the patient encounter: identifying problem symptoms and abnormal nd- ings; linking ndings to an underlying process of pathophysiology or psycho- pathology; and establishing and testing a set of explanatory hypotheses.
Work- ing through these steps will reveal the multifaceted prole of the patient before you. Paradoxically, the very skills that allow you to assess all patients also shape the image of the unique human being entrusted to your care. Clinical Assessment: The Road Ahead This chapter provides a road map to clinical prociency in three critical areas: the health history, the physical examination, and the written record, or write-up.
It describes the components of the health history and how to or- ganize the patients story; it gives an approach and overview to the physical ex- amination and suggests a sequence for ensuring patient comfort; and, nally, it provides an example of the written record, showing documentation of nd- ings from a sample patient history and physical examination. By studying the subsequent chapters of the book and perfecting the skills of examination and history taking described, you will cross into the world of patient assessment gradually at rst, but then with growing satisfaction and expertise.
After you work through this chapter to chart the tasks ahead, you will be directed by subsequent chapters in your journey to clinical competence. Once you master the elements of the adult history and examination, you will extend and adapt these techniques to children and adolescents.
Children and adolescents evolve rapidly in both temperament and physiology; therefore, the special approaches to the inter- view and examination of children at different ages are consolidated in Chap- ter 17, Assessing Children: Infancy Through Adolescence. Finally, Chapter 18, Clinical Reasoning, Assessment, and Plan, explores the clinical reasoning process and how to document your evaluation, diagnoses, and plan.
From this blend of mutual trust, respect, and clinical expertise emerges the timeless re- wards of the clinical professions. As you talk with the patient, you must learn to elicit and organize all of these elements of the patients health.
Bear in mind that dur- ing the interview this information will not spring forth in this order! How- ever, you will quickly learn to identify where to t in the different aspects of the patients story. As you gain experience assessing patients in different settings, you will nd that new patients in the ofce or in the hospital merit a comprehensive health history; however, in many situations a more exible focused, or problem- oriented, interview may be appropriate.
Like a tailor tting a special garment, you will adapt the scope of the health history to a number of factors: the pa- tients concerns and problems; your goals for assessment; the clinical setting inpatient or outpatient; specialty or primary care ; and the amount of time available.
Knowing the content and relevance of all components of the com- prehensive health history allows you to choose those elements that will be most helpful for addressing patient concerns in different contexts. The components of the comprehensive health history structure the patients story and the format of your written record, but the order shown here should not dictate the sequence of the interview.
Usually the interview will be more uid and will follow the patients leads and cues, as described in Chapter 2. Each segment of the history has a specic purpose, which is sum- marized below.
These components of the comprehensive adult health history are more fully described in the next few pages. The comprehensive pediatric history appears in Chapter Describes educational level, family of origin, current household, personal interests, and lifestyle Documents presence or absence of common symptoms related to each major body system Components of the Health History dard formats for written documentation, which will be useful for you to learn.
As you review these histories, you will encounter a number of techni- cal terms for symptoms. Denitions of terms, together with ways to ask about symptoms, can be found in each of the regional examination chapters. As you acquire the techniques of the history taking and physical examination, remember the important differences between subjective information and ob- jective information, as summarized in the table below.
Knowing these dif- ferences helps you apply clinical reasoning and cluster patient information. These distinctions are equally important for organizing written and oral pre- sentations concerning the patient. The date is always important. You are strongly advised to routinely document the time you evaluate the patient, especially in urgent, emergent, or hospital settings. Identifying Data. Includes age, gender, marital status, and occupa- tion. The source of history or referral can be the patient, a family member or friend, an ofcer, a consultant, or the medical record.
Patients requesting evaluations for schools, agencies, or insurance companies may have special priorities compared to patients seeking care on their own initiative. Desig- nating the source of referral helps you to assess the type of information pro- vided and any possible biases.
Should be documented if relevant. For example, The patient is vague when describing symptoms and unable to specify details. This judg- ment reects the quality of the information provided by the patient and is usually made at the end of the interview. Chief Complaint s Make every attempt to quote the patients own words. For example, My stomach hurts and I feel awful.
Sometimes patients have no overt com- plaints, in which case you should report their goals instead. For example, I have come for my regular checkup; or Ive been admitted for a thorough evaluation of my heart. Present Illness This section of the history is a complete, clear, and chronologic account of the problems prompting the patient to seek care. The narrative should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatments.
The principal symptoms should be well-characterized, with descriptions of 1 location, 2 quality, 3 quantity or severity, 4 tim- ing, including onset, duration, and frequency, 5 the setting in which they occur, 6 factors that have aggravated or relieved the symptoms, and 7 as- Subjective Data Objective Data What the patient tells you The history, from chief complaint through Review of Systems Example: Mrs.
G is a year-old hairdresser who reports pressure over her left chest like an elephant sitting there, which goes into her left neck and arm. What you detect on the examination All physical examination ndings Example: Mrs.
G is an older white female, deconditioned, pleasant, and cooperative. These seven attributes are invaluable for under- standing all patient symptoms see p. It is also important to include pertinent positives and pertinent negatives from sections of the Review of Systems related to the Chief Complaint s.
These designate the presence or absence of symptoms relevant to the differential diagnosis, which refers to the most likely diagnoses explaining the patients condition. Other informa- tion is frequently relevant, such as risk factors for coronary artery disease in pa- tients with chest pain, or current medications in patients with syncope. The pre- sent illness should reveal the patients responses to his or her symptoms and what effect the illness has had on the patients life.
Always remember, the data ows spontaneously from the patient, but the task of organization is yours. Medications should be noted, including name, dose, route, and frequency of use.
Also list home remedies, nonprescription drugs, vitamins, mineral or herbal supplements, birth control pills, and medicines borrowed from family members or friends. It is a good idea to ask patients to bring in all of their med- ications so you can see exactly what they take. Allergies, including specic re- actions to each medication, such as rash or nausea, must be recorded, as well as allergies to foods, insects, or environmental factors.
Note tobacco use, includ- ing the type used. Cigarettes are often reported in pack-years a person who has smoked 1 1. If some- one has quit, note for how long. Alcohol anddrug use should always be queried see p. Note that tobacco, alcohol, and drugs may also be included in the Personal and Social History; however, many clinicians nd these habits pertinent to the Present Illness.
Past History Childhood illnesses, such as measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, scarlet fever, and polio are included in the Past History. Also included are any chronic childhood illnesses. You should also cover selected aspects of Health Maintenance, including Im- munizations, such as tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, inuenza, hepatitis B, Haemophilus inuenza type b, and pneumo- coccal vaccines these can usually be obtained from prior medical records , and Screening Tests, such as tuberculin tests, Pap smears, mammograms, stools for occult blood, and cholesterol tests, together with the results and the dates they were last performed.
If the patient does not know this information, writ- ten permission may be needed to obtain old medical records. Review each of the following conditions and record if they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, cancer specify type , arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, alcohol or drug addiction, and allergies, as well as symptoms reported by the patient.
Personal and Social History The Personal and Social History captures the patients personality and inter- ests, sources of support, coping style, strengths, and fears. It should include: occupation and the last year of schooling; home situation and signicant others; sources of stress, both recent and long-term; important life experi- ences, such as military service, job history, nancial situation, and retirement; leisure activities; religious afliation and spiritual beliefs; and activities of daily living ADLs.
Baseline level of function is particularly important in older or disabled patients see p. The Personal and Social History also conveys lifestyle habits that promote health or create risk such as exercise and diet, including fre- quency of exercise, usual daily food intake, dietary supplements or restric- tions, and use of coffee, tea, and other caffeine-containing beverages and safety measures, including use of seat belts, bicycle helmets, sunblock, smoke detectors, and other devices related to specic hazards.
You may want to in- clude any alternative health care practices. You will come to thread personal and social questions throughout the inter- view to make the patient feel more at ease. Review of Systems Understanding and using Review of Systems questions is often challenging for beginning students. Think about asking series of questions going from head to toe. It is helpful to prepare the patient for the questions to come by saying, The next part of the history may feel like a million questions, but they are important and I want to be thorough.
Most Review of Systems questions pertain to symptoms, but on occasion some clinicians also include diseases like pneumonia or tuberculosis. If the patient remembers impor- tant illnesses as you ask questions within the Review of Systems, you should record or present such important illnesses as part of the Present Illness or Past History. Start with a fairly general question as you address each of the different sys- tems.
This focuses the patients attention and allows you to shift to more specic questions about systems that may be of concern. Examples of start- ing questions are: How are your ears and hearing?
How about your lungs and breathing? Any trouble with your heart? How is your digestion? Note that you will vary the need for additional questions depending on the patients age, complaints, general state of health, and your clinical judgment.
The Review of Systems questions may uncover problems that the patient has overlooked, particularly in areas unrelated to the present illness. Signicant health events, such as a major prior illness or a parents death, require full exploration.
Remember that major health events should be moved to the present illness or past history in your write-up. Keep your technique exible. Inter- viewing the patient yields a variety of information that you organize into for- mal written format only after the interview and examination are completed.
Some clinicians do the Review of Systems during the physical examination, asking about the ears, for example, as they examine them. If the patient has only a few symptoms, this combination can be efcient.
However, if there are multiple symptoms, the ow of both the history and the examination can be disrupted and necessary note-taking becomes awkward. Listed below is a standard series of review-of-system questions.
The examination will include the following tests: Pure tone audiometry by air conduction at , , , , , , and Hz, and by bone conduction at , ,. Physical Exam. A VA health professional will discuss the results face-to-face with the Veteran and in a follow-up letter. Approved structured clinical examination protocols are presented, supplemeted with a comprehensive clinical examination DVD. Engineering College was founded in
A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving. A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. A comprehensive collection of medical revision notes that cover a broad range of clinical topics. A collection of anatomy notes covering the key anatomy concepts that medical students need to learn. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management.
From Foundations of Nursing by Christensen Kockrow, pages 93 through Head to toe is completed when the patient is admitted; focused concentrates on a particular part of a body. Instruct patient to breathe through his or her mouth quietly and more deeply and slowly than in a usual respiration.
The techniques of physical examination and history taking that you are about to learn embody time-honored skills of healing and patient care. Your ability to gather a sensitive and nuanced history and to perform a thorough and accurate examination deepens your relationships with patients, focuses. History taking and physical examination can be a very exhausting experience for the patient. Remember, also, that the patient may already have been seen by other students.
Алгоритм есть уже у. Танкадо предлагает ключ, с помощью которого его можно расшифровать. - Понятно.
Его жертва не приготовилась к отпору. Хотя, быть может, подумал Халохот, Беккер не видел, как он вошел в башню. Это означало, что на его, Халохота, стороне фактор внезапности, хотя вряд ли он в этом так уж нуждается, у него и так все козыри на руках. Ему на руку была даже конструкция башни: лестница выходила на видовую площадку с юго-западной стороны, и Халохот мог стрелять напрямую с любой точки, не оставляя Беккеру возможности оказаться у него за спиной, В довершение всего Халохот двигался от темноты к свету. Расстрельная камера, мысленно усмехнулся .
Сьюзан старалась держаться поближе к шефу на небольшой платформе с металлическими поручнями. По мере того как они удалялись от двери, свет становился все более тусклым, и вскоре они оказались в полной темноте. Единственным освещением в шифровалке был разве что свет звезд над их головами, едва уловимое свечение проникало также сквозь разбитую стеклянную стену Третьего узла. Стратмор шагнул вперед, нащупывая ногой место, где начинались ступеньки узенькой лестницы. Переложив берет-ту в левую руку, правой он взялся за перила. Он прекрасно знал, что левой рукой стрелял так же плохо, как и правой, к тому же правая рука была ему нужна, чтобы поддерживать равновесие. Грохнуться с этой лестницы означало до конца дней остаться калекой, а его представления о жизни на пенсии никак не увязывались с инвалидным креслом.
Она должна немедленно поговорить со Стратмором. Сьюзан осторожно приоткрыла дверь и посмотрела на глянцевую, почти зеркальную стену шифровалки. Узнать, следит ли за ней Хейл, было невозможно. Нужно быстро пройти в кабинет Стратмора, но, конечно, не чересчур быстро: Хейл не должен ничего заподозрить.
Сидя рядом с великим Тревором Стратмором, она невольно почувствовала, что страхи ее покинули. Переделать Цифровую крепость - это шанс войти в историю, принеся громадную пользу стране, и Стратмору без ее помощи не обойтись. Хоть и не очень охотно, она все же улыбнулась: - Что будем делать. Стратмор просиял и, протянув руку, коснулся ее плеча. - Спасибо.
Халохот какое-то время наблюдал за происходящим, потом скрылся за деревьями, по-видимому, выжидая. - Сейчас произойдет передача, - предупредил Смит. - В первый раз мы этого не заметили. Сьюзан не отрываясь смотрела на эту малоприятную картину.
- Могу я чем-нибудь тебе помочь, прежде чем уйду. Он посмотрел на нее умоляюще и покрутил затекшей шеей. - У меня затекли плечи.
Да, мэм. - Я хочу услышать только да или. Возможно ли, что проблема шифровалки каким-то образом связана с вирусом. - Мидж… я уже говорил… - Да или нет: мог в ТРАНСТЕКСТ проникнуть вирус.
Чатрукьян некоторое время смотрел на него, лишившись дара речи, а потом бегом направился прочь из шифровалки. Стратмор повернулся и с удивлением увидел Хейла. Сьюзан поняла, в чем дело: все это время Хейл вел себя тихо, подозрительно тихо, поскольку отлично знал, что нет такой диагностики, в которой использовалась бы цепная мутация, тем более такая, которая занимала ТРАНСТЕКСТ уже восемнадцать часов.
ГЛАВА 104 Сьюзан вышла из комнаты. ОБЪЕКТ: ДЭВИД БЕККЕР - ЛИКВИДИРОВАН Как во сне она направилась к главному выходу из шифровалки. Голос Грега Хейла эхом отдавался в ее сознании: Сьюзан, Стратмор меня убьет, коммандер влюблен в .
Что, черт возьми, делает Фонтейн? - Смяв в кулаке бумажный стаканчик, она с силой швырнула его в бачок для мусора. - В шифровалке творится нечто непонятное. Я чувствую .
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