, TESTBANK FOR Evidence-Based Physical
Examination Best Practices for Health & Well-Being
Assessment Gawlik
Notes
1- The file is chapter after chapter.
2- We have shown you few pages sample.
3- The file contains all Appendix and Excel sheet
if it exists.
4- We have all what you need, we make update
at every time. There are many new editions
waiting you.
5- If you think you purchased the wrong file You
can contact us at every time, we can replace it
with true one.
Our email:
, Test Bank for
EVIDENCE-BASED PHYSICAL
EXAMINATION
Best Practices for Health and Well-Being
Assessment
Kate Sustersic Gawlik, DNP, APRN-CNP, FAANP
Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN
Alice M. Teall, DNP, APRN-CNP, FAANP
Editors
ISBN: 978-0-8261-6458-2
,Copyright © 2021 Springer Publishing Company, LLC
All rights reserved.
This work is protected by U.S. copyright laws and is provided solely for the use of instructors in
teaching their courses and as an aid for student learning. No part of this publication may be sold,
reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior permission of Springer
Publishing Company, LLC.
Springer Publishing Company, LLC
11 West 42nd Street
New York, NY 10036
www.springerpub.com
ISBN: 978-0-8261-6458-2
The author and the publisher of this Work have made every effort to use sources believed to be
reliable to provide information that is accurate and compatible with the standards generally
accepted at the time of publication. Because medical science is continually advancing, our
knowledge base continues to expand. Therefore, as new information becomes available, changes
in procedures become necessary. We recommend that the reader always consult current research
and specific institutional policies before performing any clinical procedure or delivering any
medication. The author and publisher shall not be liable for any special, consequential, or
exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the
information contained in this book. The publisher has no responsibility for the persistence or
accuracy of URLs for external or third-party Internet websites referred to in this publication and
does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
,Chapter 2: Evidence-Based History-Taking Approach for Wellness
Exams, Episodic Visits, and Chronic Care Management
MULTIPLE CHOICE:
1. A 20-year-old patient presents to the office for a wellness exam. The clinician assesses the patient’s
use of seat belts. Which component of the wellness exam is assessed?
a. History of present illness
b. Past medical history
c. Assessment and plan
*d. Anticipatory guidance
Wellness exam section: All wellness exams have the same general components:
• A comprehensive history and physical examination
• Anticipatory guidance, addressing risk factors and the interventions, or counselling to reduce the
identified risk factors
• Ordering appropriate immunizations, laboratory/diagnostic procedures
2. Which of the following is not an element of history taking?
a. Chief concern
b. Family history
*c. Physical examination
d. History of present illness
Episodic visit section: The general framework for the elements of history taking:
• Chief concern (CC)
• History of present illness (HPI)
• Past medical history (PMH)
• Family history (FH)
• Social history (SH)
• Review of systems (ROS)
3. Patient presents to the office with shoulder pain for 1 week. Pain is constant, burning, and reported
worse at night. During the patient interview, the clinician asks the patient “Can you tell me what you
have been doing for your shoulder pain?” The clinician is asking information about
*a. modifying factors
b. quality
c. associated signs and symptoms
d. health promotion
Episodic illness section: The history of present illness contains eight elements:
• Location (e.g., left elbow)
• Quality (e.g., aching, sharp)
• Severity (e.g., 5 on a 1–10 scale)
• Duration (e.g., started 2 days ago)
• Timing (e.g., constant)
• Context (e.g., plays tennis every day)
Copyright © Springer Publishing Company, LLC. All Rights Reserved. 1
, • Modifying factors (e.g., pain relief when ice applied)
• Associated signs and symptoms (e.g., left-hand weakness)
4. What is the difference between an open-ended question and a closed-ended question?
a. Open-ended questions are answered with yes or no; closed-ended questions are answered with
more details than yes or no.
*b. Open-ended questions have more details than simple yes or no or closed-ended questions are yes
or no answers.
c. Open-ended questions refer only to the physical exam section or closed-ended questions refer
only to the history collection.
d. The only difference between open-ended and closed-ended questions is the timing of when the
questions are asked during the patient interview.
Episodic visit section: Conducting the patient history begins with patient-centered interviewing skills
to obtain the patient’s perspective. It is important to ask open-ended questions. Open-ended questions
allow a patient to articulate his or her symptoms, including both personal and emotional information.
Open-ended questions delve deeper and often obtain discriminating features that the patient may not
even be aware of. Asking open-ended questions and allowing a patient to elaborate on his or her
symptoms ultimately saves the clinician time, in addition to providing critical clues to the diagnosis.
Clinician-centered interviewing often uses closed-ended questions to obtain answers on the basis of
the clinician’s perspective. Closed-ended questions elicit a “yes” or “no” or short-phrase response
from the patient. Closed-ended questions often make the patient feel like the subject of an
interrogation and limit both the patient and the clinician from developing a relationship.
5. A set of evidence-based recommendations for preventive services were developed by which agency?
a. U.S. Agency of Health and Human Services
b. U.S. Institute of Medicine Task Force
*c. U.S. Preventive Services Task Force
d. U.S. Center for Health and Wellness
Wellness exam section: The U.S. Preventive Services Task Force and the Centers for Disease Control
and Prevention have developed a set of evidence-based recommendations for preventive services.
6. An established patient presents for a follow-up visit for her stable hypertension. During this visit, the
clinician can update the review of systems, past medical history, family history, and social history by
simply stating the information was reviewed and updated from the previous patient encounter.
*a. True
b. False
Chronic care management visit section: Past medical history, family history, social history, review of
systems: The entire past medical history, family history, social history, and review of systems does not
have to be repeated if there is evidence that the clinician reviewed the information and updated any
previous information from an earlier patient encounter. The clinician must include in his or her
documentation the date and location of the earlier patient encounter.
2 Copyright © Springer Publishing Company, LLC. All Rights Reserved.
,7. A 70-year-old patient presents for his wellness exam a week before Thanksgiving. The patient’s last
vaccines were given when he was 40 years old. Patient states, “I don’t believe in all those shots. I
already had the chicken pox when I was a kid; that’s the best way to become immune. My kids made
me come today since I haven’t been to see a clinician in 30 years.” Which vaccines would you
recommend the patient receive today?
a. Varicella, TD, zoster, pneumococcal
b. TD, zoster, pneumococcal
*c. Influenza, Tdap, pneumococcal, zoster
d. Nasal flu mist, TD, varicella
Wellness exam section: Patients should be given the option of receiving appropriate vaccines during
the wellness exam. The immunizations schedule for adults aged 19 and older developed by the ACIP
is as follows:
• Influenza annual
• Tdap or TD with booster every 10 years
• Varicella if not immune
• Pneumococcal
• Zoster
8. When considering history collection during a wellness exam, which statement below is not correct?
a. Wellness exams do not require a chief concern.
b. Wellness exams are age and gender appropriate.
c. Wellness exam include counseling and anticipatory guidance.
*d. Wellness exams are based on a presenting problem.
Wellness examination section: History of Present Illness: Patient history collection for wellness
exams are not problem oriented and hence do not require a chief concern or history of present
illness. Rather, a wellness exam should include a comprehensive history and physical examination
appropriate to the patient’s age and gender, counseling and anticipatory guidance, risk-reduction
interventions, the ordering or administration of vaccine-appropriate immunizations, and the ordering
of appropriate laboratory and/or diagnostics. The wellness exam differs from the episodic visit or
chronic care management visit because the components of the wellness exam are based on age and
risk factors, not a presenting problem.
9. Which is true about the use of screening tools to assess depression?
*a. Screening tools like the PHQ-2 and PHQ-9 are recommended and evidence based.
b. Screening tools should be used only when the clinician is short on time for the visit.
c. Screening tools like the PHQ-2 and PHQ-9 are not to be used during wellness exams.
d. Screening tools like the PHQ-2 are too short to be effective assessments.
Wellness examination section under social history and preventive exams. Mood: Screen for
depression using PHQ-2 or PHQ-9 to confirm diagnosis and its severity. Depression screenings are
recommended in the general adult population, including pregnant and postpartum women. The
depression screening should be implemented with adequate systems in place to ensure accurate
diagnosis, effective treatment, and appropriate follow-up.
Copyright © Springer Publishing Company, LLC. All Rights Reserved. 3
,10. Weight obtained during a patient’s chronic care management follow-up visit for hypertension finds
the patient’s weight has increased 10 lb over the past year and that her body mass index (BMI) is now
in the morbidly obese category. During this visit, the clinician should place greater emphasis on
a. physical examination findings
*b. lifestyle modifications
c. updating social history
d. management of hypertension
Chronic care management section: Because of the huge impact a patient’s lifestyle has on the risk of
chronic disease, greater emphasis during chronic care visits is placed on counseling for lifestyle
modifications and risky behaviors. Time must be spent on compliance assessment and in negotiating
with patients’ specific treatments and behavior modifications that are needed over a longer period of
time. Successful lifestyle modifications include self-monitoring, feedback and problem-solving, as
well as motivation and support.
SHORT ANSWER:
1. Explain the components of the comprehensive patient interview.
Correct Answer: Episodic visit section:
Chief complaint: The chief concern is the patient’s main concern for the episodic visit. The chief
concern describes the symptom, problem, condition, diagnosis, or main reason for the visit. The chief
concern is in the patient’s own words.
History of present illness: In the history of present illness, the patient provides a narrative noting the
timing of the presenting symptom, as well as the first time the symptom occurred or the time lapse
from the previous patient encounter to the present encounter. The history of present illness contains
eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated
signs and symptoms.
Past medical history: The past medical history is the point in history taking where the patient
identifies important past medical information. This past medical history should include the patient
experiences with illnesses both acute and chronic (including pertinent childhood illnesses), surgeries,
obstetric/gynecological, and hereditary conditions that could place the patient at risk. Also included in
the past medical history is health maintenance, for example, immunizations and screening tests.
Within the past medical history, medications and other treatments are reviewed. Review allergies,
including allergies to medications, food, and environment.
Family history: Family history is a review of the immediate family members’ history related to
medical events, illnesses, and hereditary conditions that place the patient’s current and future health at
risk. Immediate family includes parents, grandparent, siblings, children, and grandchildren. Obtain
family history for at least two generation. If the person is deceased, ask about the age at death and
cause of death, especially for first-degree relatives.
Social history: Social history provides information regarding the patient’s life, which includes the
patient’s behaviors and personal choices that may impact disease risk, disease severity, and outcomes.
Address occupation, health promotion, safety, tobacco use, smoking, alcohol use, living arrangement,
sexuality, intimate partner violence, stress, mood, and health literacy.
4 Copyright © Springer Publishing Company, LLC. All Rights Reserved.
, Review of systems: The review of systems assesses the other systems or problems not already
discussed in the history of present illness. Systems included in the review of systems are as follows:
constitution, head, eyes, ears, nose, throat, cardiovascular, respiratory, gastrointestinal, genitourinary,
musculoskeletal, integumentary, neurological, psychiatric, endocrine, hematological/lymphatic, and
allergic/immunological.
2. Discuss how the use of a health coach can impact a patient’s lifestyle choices.
Correct Answer: Because of the huge impact that a patient’s lifestyle has on the risk of chronic
disease, greater emphasis during chronic care visits is placed on counseling for lifestyle modifications
and risky behaviors. Time must be spent on compliance assessment and negotiating with the patient-
specific treatments and behavior modifications that are needed over a longer period of time.
Successful lifestyle modifications include self-monitoring, feedback, and problem-solving, as well as
motivation and support. Patients need ongoing support from family and friends and counseling from
healthcare professionals. Health coaching improves quality of care and can be cost-effective for
patients with chronic conditions. Health coaches work with patients to set small achievable goals,
develop action plans, overcome barriers, and reinforce the clinician’s treatment plan. Health coaches
encourage and reinforce patient’s self-management strategies.
3. Discuss two age- and gender-appropriate counseling topics to discuss with patients during a wellness
exam.
Correct Answer: Wellness exam section: Counseling: During the wellness exam, the clinician
should include age- and gender-appropriate counseling and a discussion regarding interventions for
identified risk factors. In addition, anticipatory guidance should be provided. Counseling should also
include a conversation on preventive screenings recommended for the appropriate gender/age group.
Age-appropriate screenings should be conducted to review a patient’s functional ability and level
of safety. Appropriate screening questions or standardized questionnaires to assess activities of daily
living, fall risk, hearing impairment, and home safety should be used for age-appropriate populations.
Age-appropriate screening to assess a patient’s cognitive function should be conducted initially
by direct observation, in addition to any information reported by the patient or concerns raised by
family members, friends, caregivers, and others. If additional screening is determined to be
warranted, use validated structured cognitive assessment tools to further assess the patient’s cognitive
function.
A discussion on advance directives should be conducted with age-appropriate patients. Advance
directives assist individuals with end-of-life planning. Advance directives should include a discussion
with the patient about future care decisions that may need to be made and identifying a healthcare
decision maker. Advance directives allow patients to share with others their healthcare preferences
should they be unable to make their own healthcare decisions.
During a wellness exam review, assess for patient’s risk for depression. Include in the assessment
the patient’s current and past history of depression or any other mood disorders. Incorporate the use
of validated depression screening tools such as the PHQ9.
Copyright © Springer Publishing Company, LLC. All Rights Reserved. 5
, Chapter 3: Approach to Implementing and Documenting Patient-
Centered, Culturally Sensitive Evidence-Based Assessment
MULTIPLE CHOICE:
1. Which is true about the impact of family on an individual’s health?
a. Family has little impact on an individual’s health.
b. Family has a negative impact on an individual’s health.
*c. Family systems can impact an individual’s health and wellness needs.
d. Family systems are unlikely to impact healthy individuals.
The clinician can assess the impact of the family system during assessment of an individual’s family
health history and social history. Asking an individual whom they live with and who they consider
their support system can provide insight into family relationships, structure, function, developmental
stage, and health behaviors.
2. How does a clinician best assess the impact of an individual’s community on his or her health?
a. Assess the environment and location where the patient was born and raised.
b. Assess whether the patient has any medical conditions affecting his or her health.
c. Ask the patient if he or she has any community or cultural concerns.
*d. Ask about where the person resides, works, learns, plays, worships, and connects with others.
For the clinician assessing the health and well-being of an individual, asking about the environments
in which an individual resides, works, learns, plays, worships, and connects socially offers insight
into the impact of community in their lives. One example is the assessment of safety concerns;
recommending to someone to take daily walks outside without assessing the safety of his or her
neighborhood may have a detrimental impact on the person’s well-being if the neighborhood is
unsafe. Socioeconomic conditions, public safety, and the availability of resources in a community are
examples of social determinants of health that affect the well-being of individuals within communities.
3. What are health disparities?
a. Differences attributed to an individual’s health behaviors
*b. Differences in illness, injury, disability, or mortality experienced
c. Greater burden of implicit bias experienced
d. Greater burden of overt bias experienced
When there are significant barriers to meeting health and wellness needs within a community, the
population of the community experiences health disparities or greater burden of illness, injury,
disability, and mortality.
6 Copyright © Springer Publishing Company, LLC. All Rights Reserved.
Examination Best Practices for Health & Well-Being
Assessment Gawlik
Notes
1- The file is chapter after chapter.
2- We have shown you few pages sample.
3- The file contains all Appendix and Excel sheet
if it exists.
4- We have all what you need, we make update
at every time. There are many new editions
waiting you.
5- If you think you purchased the wrong file You
can contact us at every time, we can replace it
with true one.
Our email:
, Test Bank for
EVIDENCE-BASED PHYSICAL
EXAMINATION
Best Practices for Health and Well-Being
Assessment
Kate Sustersic Gawlik, DNP, APRN-CNP, FAANP
Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN
Alice M. Teall, DNP, APRN-CNP, FAANP
Editors
ISBN: 978-0-8261-6458-2
,Copyright © 2021 Springer Publishing Company, LLC
All rights reserved.
This work is protected by U.S. copyright laws and is provided solely for the use of instructors in
teaching their courses and as an aid for student learning. No part of this publication may be sold,
reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior permission of Springer
Publishing Company, LLC.
Springer Publishing Company, LLC
11 West 42nd Street
New York, NY 10036
www.springerpub.com
ISBN: 978-0-8261-6458-2
The author and the publisher of this Work have made every effort to use sources believed to be
reliable to provide information that is accurate and compatible with the standards generally
accepted at the time of publication. Because medical science is continually advancing, our
knowledge base continues to expand. Therefore, as new information becomes available, changes
in procedures become necessary. We recommend that the reader always consult current research
and specific institutional policies before performing any clinical procedure or delivering any
medication. The author and publisher shall not be liable for any special, consequential, or
exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the
information contained in this book. The publisher has no responsibility for the persistence or
accuracy of URLs for external or third-party Internet websites referred to in this publication and
does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
,Chapter 2: Evidence-Based History-Taking Approach for Wellness
Exams, Episodic Visits, and Chronic Care Management
MULTIPLE CHOICE:
1. A 20-year-old patient presents to the office for a wellness exam. The clinician assesses the patient’s
use of seat belts. Which component of the wellness exam is assessed?
a. History of present illness
b. Past medical history
c. Assessment and plan
*d. Anticipatory guidance
Wellness exam section: All wellness exams have the same general components:
• A comprehensive history and physical examination
• Anticipatory guidance, addressing risk factors and the interventions, or counselling to reduce the
identified risk factors
• Ordering appropriate immunizations, laboratory/diagnostic procedures
2. Which of the following is not an element of history taking?
a. Chief concern
b. Family history
*c. Physical examination
d. History of present illness
Episodic visit section: The general framework for the elements of history taking:
• Chief concern (CC)
• History of present illness (HPI)
• Past medical history (PMH)
• Family history (FH)
• Social history (SH)
• Review of systems (ROS)
3. Patient presents to the office with shoulder pain for 1 week. Pain is constant, burning, and reported
worse at night. During the patient interview, the clinician asks the patient “Can you tell me what you
have been doing for your shoulder pain?” The clinician is asking information about
*a. modifying factors
b. quality
c. associated signs and symptoms
d. health promotion
Episodic illness section: The history of present illness contains eight elements:
• Location (e.g., left elbow)
• Quality (e.g., aching, sharp)
• Severity (e.g., 5 on a 1–10 scale)
• Duration (e.g., started 2 days ago)
• Timing (e.g., constant)
• Context (e.g., plays tennis every day)
Copyright © Springer Publishing Company, LLC. All Rights Reserved. 1
, • Modifying factors (e.g., pain relief when ice applied)
• Associated signs and symptoms (e.g., left-hand weakness)
4. What is the difference between an open-ended question and a closed-ended question?
a. Open-ended questions are answered with yes or no; closed-ended questions are answered with
more details than yes or no.
*b. Open-ended questions have more details than simple yes or no or closed-ended questions are yes
or no answers.
c. Open-ended questions refer only to the physical exam section or closed-ended questions refer
only to the history collection.
d. The only difference between open-ended and closed-ended questions is the timing of when the
questions are asked during the patient interview.
Episodic visit section: Conducting the patient history begins with patient-centered interviewing skills
to obtain the patient’s perspective. It is important to ask open-ended questions. Open-ended questions
allow a patient to articulate his or her symptoms, including both personal and emotional information.
Open-ended questions delve deeper and often obtain discriminating features that the patient may not
even be aware of. Asking open-ended questions and allowing a patient to elaborate on his or her
symptoms ultimately saves the clinician time, in addition to providing critical clues to the diagnosis.
Clinician-centered interviewing often uses closed-ended questions to obtain answers on the basis of
the clinician’s perspective. Closed-ended questions elicit a “yes” or “no” or short-phrase response
from the patient. Closed-ended questions often make the patient feel like the subject of an
interrogation and limit both the patient and the clinician from developing a relationship.
5. A set of evidence-based recommendations for preventive services were developed by which agency?
a. U.S. Agency of Health and Human Services
b. U.S. Institute of Medicine Task Force
*c. U.S. Preventive Services Task Force
d. U.S. Center for Health and Wellness
Wellness exam section: The U.S. Preventive Services Task Force and the Centers for Disease Control
and Prevention have developed a set of evidence-based recommendations for preventive services.
6. An established patient presents for a follow-up visit for her stable hypertension. During this visit, the
clinician can update the review of systems, past medical history, family history, and social history by
simply stating the information was reviewed and updated from the previous patient encounter.
*a. True
b. False
Chronic care management visit section: Past medical history, family history, social history, review of
systems: The entire past medical history, family history, social history, and review of systems does not
have to be repeated if there is evidence that the clinician reviewed the information and updated any
previous information from an earlier patient encounter. The clinician must include in his or her
documentation the date and location of the earlier patient encounter.
2 Copyright © Springer Publishing Company, LLC. All Rights Reserved.
,7. A 70-year-old patient presents for his wellness exam a week before Thanksgiving. The patient’s last
vaccines were given when he was 40 years old. Patient states, “I don’t believe in all those shots. I
already had the chicken pox when I was a kid; that’s the best way to become immune. My kids made
me come today since I haven’t been to see a clinician in 30 years.” Which vaccines would you
recommend the patient receive today?
a. Varicella, TD, zoster, pneumococcal
b. TD, zoster, pneumococcal
*c. Influenza, Tdap, pneumococcal, zoster
d. Nasal flu mist, TD, varicella
Wellness exam section: Patients should be given the option of receiving appropriate vaccines during
the wellness exam. The immunizations schedule for adults aged 19 and older developed by the ACIP
is as follows:
• Influenza annual
• Tdap or TD with booster every 10 years
• Varicella if not immune
• Pneumococcal
• Zoster
8. When considering history collection during a wellness exam, which statement below is not correct?
a. Wellness exams do not require a chief concern.
b. Wellness exams are age and gender appropriate.
c. Wellness exam include counseling and anticipatory guidance.
*d. Wellness exams are based on a presenting problem.
Wellness examination section: History of Present Illness: Patient history collection for wellness
exams are not problem oriented and hence do not require a chief concern or history of present
illness. Rather, a wellness exam should include a comprehensive history and physical examination
appropriate to the patient’s age and gender, counseling and anticipatory guidance, risk-reduction
interventions, the ordering or administration of vaccine-appropriate immunizations, and the ordering
of appropriate laboratory and/or diagnostics. The wellness exam differs from the episodic visit or
chronic care management visit because the components of the wellness exam are based on age and
risk factors, not a presenting problem.
9. Which is true about the use of screening tools to assess depression?
*a. Screening tools like the PHQ-2 and PHQ-9 are recommended and evidence based.
b. Screening tools should be used only when the clinician is short on time for the visit.
c. Screening tools like the PHQ-2 and PHQ-9 are not to be used during wellness exams.
d. Screening tools like the PHQ-2 are too short to be effective assessments.
Wellness examination section under social history and preventive exams. Mood: Screen for
depression using PHQ-2 or PHQ-9 to confirm diagnosis and its severity. Depression screenings are
recommended in the general adult population, including pregnant and postpartum women. The
depression screening should be implemented with adequate systems in place to ensure accurate
diagnosis, effective treatment, and appropriate follow-up.
Copyright © Springer Publishing Company, LLC. All Rights Reserved. 3
,10. Weight obtained during a patient’s chronic care management follow-up visit for hypertension finds
the patient’s weight has increased 10 lb over the past year and that her body mass index (BMI) is now
in the morbidly obese category. During this visit, the clinician should place greater emphasis on
a. physical examination findings
*b. lifestyle modifications
c. updating social history
d. management of hypertension
Chronic care management section: Because of the huge impact a patient’s lifestyle has on the risk of
chronic disease, greater emphasis during chronic care visits is placed on counseling for lifestyle
modifications and risky behaviors. Time must be spent on compliance assessment and in negotiating
with patients’ specific treatments and behavior modifications that are needed over a longer period of
time. Successful lifestyle modifications include self-monitoring, feedback and problem-solving, as
well as motivation and support.
SHORT ANSWER:
1. Explain the components of the comprehensive patient interview.
Correct Answer: Episodic visit section:
Chief complaint: The chief concern is the patient’s main concern for the episodic visit. The chief
concern describes the symptom, problem, condition, diagnosis, or main reason for the visit. The chief
concern is in the patient’s own words.
History of present illness: In the history of present illness, the patient provides a narrative noting the
timing of the presenting symptom, as well as the first time the symptom occurred or the time lapse
from the previous patient encounter to the present encounter. The history of present illness contains
eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated
signs and symptoms.
Past medical history: The past medical history is the point in history taking where the patient
identifies important past medical information. This past medical history should include the patient
experiences with illnesses both acute and chronic (including pertinent childhood illnesses), surgeries,
obstetric/gynecological, and hereditary conditions that could place the patient at risk. Also included in
the past medical history is health maintenance, for example, immunizations and screening tests.
Within the past medical history, medications and other treatments are reviewed. Review allergies,
including allergies to medications, food, and environment.
Family history: Family history is a review of the immediate family members’ history related to
medical events, illnesses, and hereditary conditions that place the patient’s current and future health at
risk. Immediate family includes parents, grandparent, siblings, children, and grandchildren. Obtain
family history for at least two generation. If the person is deceased, ask about the age at death and
cause of death, especially for first-degree relatives.
Social history: Social history provides information regarding the patient’s life, which includes the
patient’s behaviors and personal choices that may impact disease risk, disease severity, and outcomes.
Address occupation, health promotion, safety, tobacco use, smoking, alcohol use, living arrangement,
sexuality, intimate partner violence, stress, mood, and health literacy.
4 Copyright © Springer Publishing Company, LLC. All Rights Reserved.
, Review of systems: The review of systems assesses the other systems or problems not already
discussed in the history of present illness. Systems included in the review of systems are as follows:
constitution, head, eyes, ears, nose, throat, cardiovascular, respiratory, gastrointestinal, genitourinary,
musculoskeletal, integumentary, neurological, psychiatric, endocrine, hematological/lymphatic, and
allergic/immunological.
2. Discuss how the use of a health coach can impact a patient’s lifestyle choices.
Correct Answer: Because of the huge impact that a patient’s lifestyle has on the risk of chronic
disease, greater emphasis during chronic care visits is placed on counseling for lifestyle modifications
and risky behaviors. Time must be spent on compliance assessment and negotiating with the patient-
specific treatments and behavior modifications that are needed over a longer period of time.
Successful lifestyle modifications include self-monitoring, feedback, and problem-solving, as well as
motivation and support. Patients need ongoing support from family and friends and counseling from
healthcare professionals. Health coaching improves quality of care and can be cost-effective for
patients with chronic conditions. Health coaches work with patients to set small achievable goals,
develop action plans, overcome barriers, and reinforce the clinician’s treatment plan. Health coaches
encourage and reinforce patient’s self-management strategies.
3. Discuss two age- and gender-appropriate counseling topics to discuss with patients during a wellness
exam.
Correct Answer: Wellness exam section: Counseling: During the wellness exam, the clinician
should include age- and gender-appropriate counseling and a discussion regarding interventions for
identified risk factors. In addition, anticipatory guidance should be provided. Counseling should also
include a conversation on preventive screenings recommended for the appropriate gender/age group.
Age-appropriate screenings should be conducted to review a patient’s functional ability and level
of safety. Appropriate screening questions or standardized questionnaires to assess activities of daily
living, fall risk, hearing impairment, and home safety should be used for age-appropriate populations.
Age-appropriate screening to assess a patient’s cognitive function should be conducted initially
by direct observation, in addition to any information reported by the patient or concerns raised by
family members, friends, caregivers, and others. If additional screening is determined to be
warranted, use validated structured cognitive assessment tools to further assess the patient’s cognitive
function.
A discussion on advance directives should be conducted with age-appropriate patients. Advance
directives assist individuals with end-of-life planning. Advance directives should include a discussion
with the patient about future care decisions that may need to be made and identifying a healthcare
decision maker. Advance directives allow patients to share with others their healthcare preferences
should they be unable to make their own healthcare decisions.
During a wellness exam review, assess for patient’s risk for depression. Include in the assessment
the patient’s current and past history of depression or any other mood disorders. Incorporate the use
of validated depression screening tools such as the PHQ9.
Copyright © Springer Publishing Company, LLC. All Rights Reserved. 5
, Chapter 3: Approach to Implementing and Documenting Patient-
Centered, Culturally Sensitive Evidence-Based Assessment
MULTIPLE CHOICE:
1. Which is true about the impact of family on an individual’s health?
a. Family has little impact on an individual’s health.
b. Family has a negative impact on an individual’s health.
*c. Family systems can impact an individual’s health and wellness needs.
d. Family systems are unlikely to impact healthy individuals.
The clinician can assess the impact of the family system during assessment of an individual’s family
health history and social history. Asking an individual whom they live with and who they consider
their support system can provide insight into family relationships, structure, function, developmental
stage, and health behaviors.
2. How does a clinician best assess the impact of an individual’s community on his or her health?
a. Assess the environment and location where the patient was born and raised.
b. Assess whether the patient has any medical conditions affecting his or her health.
c. Ask the patient if he or she has any community or cultural concerns.
*d. Ask about where the person resides, works, learns, plays, worships, and connects with others.
For the clinician assessing the health and well-being of an individual, asking about the environments
in which an individual resides, works, learns, plays, worships, and connects socially offers insight
into the impact of community in their lives. One example is the assessment of safety concerns;
recommending to someone to take daily walks outside without assessing the safety of his or her
neighborhood may have a detrimental impact on the person’s well-being if the neighborhood is
unsafe. Socioeconomic conditions, public safety, and the availability of resources in a community are
examples of social determinants of health that affect the well-being of individuals within communities.
3. What are health disparities?
a. Differences attributed to an individual’s health behaviors
*b. Differences in illness, injury, disability, or mortality experienced
c. Greater burden of implicit bias experienced
d. Greater burden of overt bias experienced
When there are significant barriers to meeting health and wellness needs within a community, the
population of the community experiences health disparities or greater burden of illness, injury,
disability, and mortality.
6 Copyright © Springer Publishing Company, LLC. All Rights Reserved.
