Clinical Assessment
last authored: Jan 2010, David LaPierre
last reviewed:
This clinical assessment is composed of the history and physical exam. The components of these are best learned early during training, as some aspects can require substantial skill. As training progresses for some professions, such as physicians and nurses, a differential diagnosis should be occurring throughout the interview, guiding questions and physical exam.
- history
- physical exam
History
components of the history
A great history elicits important and standardized information from patients, but does so in a natural way. Be curious and open while building trust and rapport. Summarize and get further information using a patient's own words. Ask screening questions about other categories during the HPI.
Identifying Data
get to know the patient a bit before diving in - name, age, occupation, who's at home. Some options are:
- as we get started, I'd like to know a bit about who you are as a person. Can you tell me about yourself in a few sentences?"
- "tell me a little bit about who you are"
See if you can engage their private voice if possible to set the tone of the interview.
Chief Concern
- use patient's words
- let them talk for a good amount of time
History of Presenting Illness
Palliative and provocative factors
Quality or Character
Region (as exact as possible)
Severity or amount
Timing: (frequency, onset, duration, course)
Other Symptoms
Disability and adaptation/impact on life situation
Relevant medical history, risk factors.
Previous physician visits, investigations, therapies
Effects on
Past Medical History
- medical
- surgical
- preventive (ie vaccinations, Pap smears, breast exams
- childhood health
Medications
- prescriptions
- over the counter
- herbal
- caffeine, alcohol, nicotine
Allergies must be inquired into. Ask about dates, types, and severity of response.
Social History
Tell me about your living situation...
Instead of 'who is your next of kin', can say 'is there someone you'd like to be involved if you got sick'?
Occupations
Who is at home?
Education, Travel, Hobbies
Economics, i.e. Do they have a drug plan?
Family History
There are a number of diseases and conditions with genetic causes and potential risk of inheritance, and a well-done family history can be valuable in identifying them. As one author wrote, "to fail to take a good family history is bad medicine and someday will be criminal negligence" (Childs B, 1982).
Construct a pedigree if relevant.
Functional Inquiry
The current state of the patient.
General: Weight, Fatigue, General well-being, Fever, Chills, Sweats
Current Health: Sleep, Diet
Learn symptoms for systems.
Summarize at the end of the interview, which is perhaps the most important time.
Physical Exam
The physical exam flows from the patient history, and should be focused according to the differential diagnosis. Specific aspects of the physical exam are as follows:
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General Advice
A recurring progression of steps is IPPA: inspection, palpation, percussion, auscultation.
Good References
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