Clinical Evaluation

This page will build on history and physical and differential diagnosis, learned during introductory years, to blending them together, which should begin occurring during senior years.

The differential diagnosis should be occurring throughout the interview, guiding questions. It should also guide physical exam.

 

  • history
  • physical exam

Taking a Great History

A great history elicits important and standardized information from patients, but does so in a natural way. Combined with the physical exam, impressions about the patient can be made.

Pediatric history

 

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
    • OTC
    • herbal
    • caffeine, alcohol, nicotine
    • allergies

 

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 histroy 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.

 

Great Advice

  • 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

 

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Physical Exam

The physical exam is important. Together with the patient history, it helps form an impression of the patient.

 

Examination:

1. General Observation
2. Vital Signs
3. Head and Neck
4. Chest, breast
5. Cardiovascular
6. Abdominal
7. Rectal/ genital
8. Musculo-skeletal
9. Neurological
10. Skin
 

Pediatric Exam

 

Good References

JAMA Rational Clinical Exam