1A: Clinical Assessment

Clinical

Related to direct observation & treatment of actual patients rather than theoretical or laboratory studies.

Assessment

Evaluation or estimation of the nature, quality, or ability of someone or something.

Patient’s Chart

Includes everything about the patient, what doctors refer to when they want to know how the patient is doing.

History

The subjective part of the patient encounter based on what they say.

Chief Complaint, History of Present Illness (HPI), Review of Symptoms, Past Medical History, Family History, & Personal & Social History

The 6 parts of History.

Chief Complaint

The 1st part of history that answers why a patient sought out consultation, their reason for seeking medical care, and something that must be addressed.

History of Present Illness (HPI)

The 1st part of history that involves looking at how a patient’s symptoms developed through a timeline and focuses on their current condition.

Symptomatology

Involved in looking at a HPI, specifically the term for how the symptoms of a patient develop.

Onset, Provoking/Palliating, Quality, Region/Radiation, Severity, & Timing

The 6 elements looked at in smyptomatology.

Review of Systems

The 3rd part of history that is asked in a checklist form to provide a bigger picture to a patient’s condition.

General, Musculoskeletal/Integumentary, HEENT, Respiratory, Cardiovascular, Gastrointestinal, Endocrine, Genitourinary, & Neurological

Systems that are reviewed in checklist form during a review of symptoms when looking at a patient’s history. (10 total categories)

Past Medical History

The 4th part of history that looks at chronic diseases, previous hospitalizations, current medicines, current diseases, & past illnesses.

Family History

The 5th part of history that looks at possible heritable diseases & genetic predispositions.

Children & Elderly

The 2 age groups that are important in looking at the immune systems of.

Personal & Social History

The 6th part of history that looks at environmental risk factors, educational attainment, and occupation.

Physical Exam

The objective part of assessing the patient based on your own observations as a doctor.

General Survey, Head & Neck Exam, Anterior & Posterior Chest Exam, Abdominal Exam, & Extremities

The 5 parts of a physical exam.

Anthropometrics, Vital Signs, & Pain Scale

The 3 parts of a general survey given during a physical exam.

Anthropometrics

The part of a general survey given during a physical exam that asks for height, weight, BMI, Head, Chest, & Abdominal Circumference.

Vital Signs

The part of a general survey given during a physical exam that asks for heart rate, temperature, blood pressure, and respiration rate.

Pain Scale

The part of a general survey given during a physical exam where doctors observe the level of pain a patient feels.

Malingering

The official term for patients who fake conditions.

Primary Impression/Assessment

The diagnosis thus far given what you get as a doctor after looking at the patient’s history & physical exam.

Differential Diagnosis

Multiple diagnoses that are at a minimum of 2-3 that help you narrow down your diagnosis.

Diagnostic & Therapeutic

The 2 kinds of plans you could give as a doctor.

Diagnostic Plan

Tests you do to confirm an impression & eliminate differentials.

Therapeutic Plan

What you will do to relieve the symptoms of the patient & address the chief complaint they have.

Subjective, Objective, Assessment, Plan notes

The definition of SOAP notes.

Subjective notes

The part of SOAP notes where findings about what a patient tells you about their feelings & history are placed.

Objective notes

The part of SOAP notes where findings about what you observe, measure, or test during the encounter are placed.

Assessment notes

The part of SOAP notes where findings about your clinical diagnosis & analysis of he current situation are placed.

Plan notes

The part of SOAP notes where findings about the exact steps, treatments, & follow-ups you will perform next are placed.

Problem-Based & Team Based

The 2 alternative forms of learning against traditional learning.

Problem-Based Learning

A form of learning that uses a flip-based classroom model where you start with a case, define terms, make guide questions that are then organized & ranked, study, and then return to a group discussion in the succeeding session.

Team-Based Learning

A form of learning that involves reading or being lectured in advance, being given an individual quiz, then a group quiz, followed by a short lecture. It is more tightly structured and teams are set for the whole course.