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Complete medical evaluation includes a medical history, a physical
examination, appropriate laboratory o studies, analysis of data
and medical decision making to obtain diagnoses, and treatment plan.
The components of the medical history are:
Chief complaint the reason for the current medical
visit.
History of present illness - the chronological order
of events of symptoms. A mnemonic PQRST is sometimes
helpful in obtaining the history:
Provocative-palliative factors - what makes a symptom
worse or better.
Quality - description of the symptom Region - which
part of the body is affected Severity - what is the
intensity of the symptom; using a scale of 0-10
Timing - what is the course of the symptom
Current activity - occupation, hobbies, what the patient
actually does.
Medications - what drugs including OTCs, and home remedies,
as well as herbal remedies such as St. John's Wort.
Allergies are recorded.
Past medical history (PMH/PMHx) - other medical diagnoses,
past hospitalizations and operations, injuries, past
infectious diseases and/or vaccinations, history of
known allergies.
Review of systems (ROS) - an outline of additional symptoms
to ask which may be missed on HPI, generally following
the body's main organ systems (heart, lungs, digestive
tract, urinary tract, etc).
Social history (SH) - birthplace, residences, marital
history, social and economic status, habits (including
diet, drugs, tobacco, alcohol).
Family history (FH) - listing of diseases in the family
that may impact the patient. A family tree is sometimes
used.
The physical examination is the examination of the patient looking
for signs of disease. The doctor uses his senses of sight, hearing,
touch, and sometimes smell (taste has been made redundant by the
availability of modern lab tests). Four chief methods are used:
inspection, palpation, percussion, and auscultation; smelling may
be useful (e.g. infection, uremia, diabetic ketoacidosis). The clinical
examination involves study of:
Vital signs include height, weight, body temperature,
, plse, respiration rate, hemoglobin oxygen saturation
General appearance of the patient
Head, eye, ear, nose, and throat
Cardiovascular - heart and blood vessels
Respiratory - lungs
Abdomen and rectosigmoid
Genitalia
Spine and extremities - musculoskeletal
Neurological and psychiatric
Laboratory and imaging studies results may be obtained, if necessary.
The medical decision-making (MDM) process involves
analysis and synthesis of all the above data to come up with a list
of possible diagnoses (the differential diagnoses), along with an
idea of what needs to be done to obtain a definitive diagnosis that
would explain the patient's problem.
The treatment plan may include ordering additional
laboratory tests and studies, starting therapy, referral to a specialist,
or watchful observation. Follow-up may be advised.
This process is used by primary care providers as
well as specialists.It may take only a few minutes if the problem
is simple and straightforward. On the other hand, it may take weeks
in a patient who has been hospitalized with multi-system problems,
with involvement by several specialists.
On subsequent visits, the process may be repeated
in an abbreviated manner to obtain any new history, symptoms, physical
findings, and lab or imaging results or specialist consultations.
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