Examination and History
Taking 2026 Expert Verifed Ace
the Text
Comprehensive health history - ANSWER ✔✔A detailed account of a
patient's health status, appropriate for new patients establishing care.
Components of health history - ANSWER ✔✔Includes review of
systems, present illness, personal and social items, but excludes thorax
and lungs.
Subjective information - ANSWER ✔✔Information given by the
patient about their symptoms, such as shortness of breath.
,Objective information - ANSWER ✔✔Measurements obtained by the
examiner, such as respiratory rate and pulse rate.
Present illness - ANSWER ✔✔Describes the current health problem,
including details like location, timing, severity, and associated symptoms.
Personal and social history - ANSWER ✔✔Includes educational level,
family status, employment, and lifestyle factors.
Chief complaint - ANSWER ✔✔The primary issue reported by the
patient, often quoted in their own words.
Review of systems - ANSWER ✔✔Documents the presence or
absence of common symptoms related to each major body system.
Surgeries - ANSWER ✔✔Records surgical procedures the patient
has undergone, such as cesarean sections.
Adult illnesses - ANSWER ✔✔Includes chronic illnesses, significant
hospitalizations, and major procedures.
Asthma exacerbation - ANSWER ✔✔A significant respiratory event
that may require hospitalization.
,Musculoskeletal chest pain - ANSWER ✔✔Chest pain that may be
due to conditions like costochondritis or intercostal muscle cramp,
worsened by chest wall motion.
Cardiac disorders - ANSWER ✔✔Conditions like congestive heart
failure that are likely to cause symptoms such as shortness of breath.
Thorax and lungs - ANSWER ✔✔Part of the physical examination,
not included in the health history.
Respiratory rate - ANSWER ✔✔A measurement of breaths per
minute, considered objective data.
Pulse rate - ANSWER ✔✔A measurement of heartbeats per minute,
considered objective data.
Severity scale - ANSWER ✔✔A method to quantify pain, often rated
from 1 to 10.
Nausea and vomiting - ANSWER ✔✔Symptoms that may accompany
abdominal pain.
Mid-epigastric area - ANSWER ✔✔The location in the abdomen
where the patient reports pain.
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, Patient assessment - ANSWER ✔✔The process of gathering
comprehensive or focused health information about a patient.
Health history categories - ANSWER ✔✔Include chief complaint,
present illness, personal and social history, and review of systems.
Significant hospitalization - ANSWER ✔✔An important event in a
patient's health history, such as treatment for asthma.
Pleuritic chest pain - ANSWER ✔✔Sharp chest pain that increases
with deep breathing, often due to pleural inflammation.
Emergency room evaluation - ANSWER ✔✔Assessment of acute
symptoms, such as shortness of breath.
Anatomic regions for symptoms - ANSWER ✔✔Categories such as
musculoskeletal, reproductive, urinary, cardiac, and hematologic.
Patient's own words - ANSWER ✔✔Quoting the patient directly in the
chief complaint section.
Associated manifestations - ANSWER ✔✔Symptoms that accompany
the primary complaint, such as nausea with abdominal pain.
Educational level - ANSWER ✔✔Part of personal and social history,
indicating the highest grade completed by the patient.