The ability to obtain an accurate medical history and carefully perform a physical examination is fundamental to providing comprehensive care to adult patients. In particular, the internist must be thorough and efficient in obtaining a history and performing a physical exam with a wide variety of patients, including healthy adults (both young and old), adults with acute and chronic medical problems, and adults with complex life-threatening diseases. Show The optimal selection of diagnostic tests, choice of treatment, and use of subspecialists, as well as the physician’s relationship and rapport with patients, all depend on well developed history-taking and physical-diagnosis skills. These skills, which are fundamental to effective patient care should be a primary focus of the student’s work during the core clerkship in general internal medicine. The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013). Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). The hospital will have a form with assessment questions similar to the ones listed in Checklist 16. Checklist 16: Health History ChecklistDisclaimer: Always review and follow your hospital policy regarding this specific skill.StepsAdditional InformationDetermine the following:1. Biographical data
What are the 3 components of physical assessment?WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen.
What are the 4 method of physical examination?A physical examination usually includes:. Inspection (looking at the body). Palpation (feeling the body with fingers or hands). Auscultation (listening to sounds). Percussion (producing sounds, usually by tapping on specific areas of the body). What are the four 4 physical examination techniques use in assessing a patient to obtain the objective data?In this chapter, you will focus on four objective assessment techniques: inspection, palpation, percussion, and auscultation.
What are the correct steps for physical assessment?Physical examination. 1 Inspection.. 2 Palpation.. 3 Auscultation.. 4 Percussion.. |