Assignment: Course Resources Area

Assignment: Course Resources Area

Assignment: Course Resources Area

Week 1: Clinical Reasoning and the Physical Assessment Using course materials, textbooks, and the SOAP Note Format document provided in the Course Resources area of the course, choose a friend, colleague, or family member and perform a complete history on your “patient” that presents for a history and physical examination. This is the kind of history you might obtain from a new patient, or during an annual well-visit exam. You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of fatigue, fever, and muscles aches. You should include a complete ROS and all the other components of a complete patient history. This week you will only need to document thesubjective portion of the SOAP note (not objective). Document your findings in a systematic manner and identify some of the key components of the history that may tip you off to primary care interventions that this patient may require. Share these findings in this discussion.

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© homeworkjoy.comPhysical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient’s history and pathophysiology. Moreover, it is a unique situation in which both patient and physician understand that the interaction is intended to be diagnostic and therapeutic. The physical examination, thoughtfully performed, should yield 20% of the data necessary for patient diagnosis and management.Almost without exception, some medical history about the patient is available at the time of the physical examination. Rarely, there may be no history, or at best brief recordings of acute events. Information pertinent to the physical examination can be learned from observation of speech, gestures, habits, gait, and manipulation of features and extremities. Interactions with relatives and staff are often revealing. Pigmentary changes such as cyanosis, jaundice, and pallor may be noted. Diaphoresis, blanching, and flushing may provide clues about vasomotor tone related to mood or physiologic abnormalities. Aspects of patient habits, interests, and relationships can be ascertained from pictures, books, magazines, and personal objects at the bedside.