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 many aspects can require substantial practice to gain mastery. 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

identifying data
chief concern
history of presenting illness
past medical history
medications
social history
family history
functional inquiry

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.

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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: