PHYSICAL EXAMINATION AND HISTORY
TAKING CLINICAL SKILLS TEST PAPER
QUESTIONS AND SOLUTIONS VERIFIED
ANSWERS
●● holistic:
Answer: Considering the patient as a whole; includes the physical,
emotional, social, economic, and spiritual needs of the person.
●● differential diagnosis
Answer: Considers which one of several diseases may be producing the
patient's symptoms. The possible causes for a set of symptoms are
considered in order to arrive at a diagnosis. A differential diagnosis is
based on information gathered from the patient about symptoms;
contributing family, personal, and social histories; and a complete
physical examination.
●● clinical diagnosis
Answer: The clinical diagnosis is arrived at after taking a detailed
history and doing a comprehensive physical examination, but before any
laboratory tests or x-rays, diagnostic testing is done.
●● Collecting the History Information
Answer: The documentation should include the following:
,• Purpose of the patient's visit, written as the chief complaint (CC)
• Patient's vital signs (VS)
• Height and weight
• Pain; documented using a scale of 1 to 10, with 1 being the least
amount of pain and 10 being the greatest amount. In some facilities, the
provider takes the medical history during the patient's initial visit.
●● Components of the Medical History
Answer: Database, Chief complaint (CC), History of present illness
(HPI), Past history (PH) or past medical history (PMH), Family history
(FH), Social history (SH), Systems review (SR) or review of systems
(ROS).
●● Database
Answer: The record of the patient's demographic information along with
history, physical examination, and initial laboratory findings. As new
information is added, it becomes part of this database.
●● Chief complaint (CC)
Answer: The purpose of the patient's visit. Generally, this is documented
in the patient's own words.
●● History of present illness (HPI)
,Answer: The medical assistant should gather as much information about
the health problem as possible and document it concisely in chronologic
order.
Describes the signs and symptoms from the time of onset.
●● Past history (PH) or past medical history (PMH)
Answer: A summary of the patient's previous health. It includes dates
and details about the patient:
• Usual childhood diseases (UCD or UCHD)
• Major illnesses
• Surgeries
• Allergies
• Accidents
• Immunization record
●● Family history (FH)
Answer: Details about the patient's parents and siblings and their health;
if they are deceased, the age and cause of death. This information is
important because certain diseases and disorders have familial or
hereditary tendencies.
●● Social history (SH)
Answer: This section includes information about the patient's lifestyle:
, • Whether he or she feels safe at home
• Use of tobacco, alcohol, or recreational drugs
• Sleeping and exercise habits
• Typical diet
• Education and occupation
• Dental care history
• For female patients, their last menstrual period (LMP), pregnancy
history, and method of birth control if sexually active.
●● Systems review (SR) or review of systems (ROS)
Answer: A systems review is obtained through a logical sequence of
questions about the state of health of body systems, beginning with the
head and proceeding downward. The provider typically completes this
section of the medical history while conducting the physical
examination.
●● Allergy Documentation
Answer: Each medical practice has a policy on how to document a
patient's allergies. In a paper record, they typically are written in red ink
or identified by a colored sticker so that all healthcare workers can easily
see it. EHR systems have methods for including allergy information on
all pertinent screens in the patient's record.
●● Understanding and Communicating With Patients
TAKING CLINICAL SKILLS TEST PAPER
QUESTIONS AND SOLUTIONS VERIFIED
ANSWERS
●● holistic:
Answer: Considering the patient as a whole; includes the physical,
emotional, social, economic, and spiritual needs of the person.
●● differential diagnosis
Answer: Considers which one of several diseases may be producing the
patient's symptoms. The possible causes for a set of symptoms are
considered in order to arrive at a diagnosis. A differential diagnosis is
based on information gathered from the patient about symptoms;
contributing family, personal, and social histories; and a complete
physical examination.
●● clinical diagnosis
Answer: The clinical diagnosis is arrived at after taking a detailed
history and doing a comprehensive physical examination, but before any
laboratory tests or x-rays, diagnostic testing is done.
●● Collecting the History Information
Answer: The documentation should include the following:
,• Purpose of the patient's visit, written as the chief complaint (CC)
• Patient's vital signs (VS)
• Height and weight
• Pain; documented using a scale of 1 to 10, with 1 being the least
amount of pain and 10 being the greatest amount. In some facilities, the
provider takes the medical history during the patient's initial visit.
●● Components of the Medical History
Answer: Database, Chief complaint (CC), History of present illness
(HPI), Past history (PH) or past medical history (PMH), Family history
(FH), Social history (SH), Systems review (SR) or review of systems
(ROS).
●● Database
Answer: The record of the patient's demographic information along with
history, physical examination, and initial laboratory findings. As new
information is added, it becomes part of this database.
●● Chief complaint (CC)
Answer: The purpose of the patient's visit. Generally, this is documented
in the patient's own words.
●● History of present illness (HPI)
,Answer: The medical assistant should gather as much information about
the health problem as possible and document it concisely in chronologic
order.
Describes the signs and symptoms from the time of onset.
●● Past history (PH) or past medical history (PMH)
Answer: A summary of the patient's previous health. It includes dates
and details about the patient:
• Usual childhood diseases (UCD or UCHD)
• Major illnesses
• Surgeries
• Allergies
• Accidents
• Immunization record
●● Family history (FH)
Answer: Details about the patient's parents and siblings and their health;
if they are deceased, the age and cause of death. This information is
important because certain diseases and disorders have familial or
hereditary tendencies.
●● Social history (SH)
Answer: This section includes information about the patient's lifestyle:
, • Whether he or she feels safe at home
• Use of tobacco, alcohol, or recreational drugs
• Sleeping and exercise habits
• Typical diet
• Education and occupation
• Dental care history
• For female patients, their last menstrual period (LMP), pregnancy
history, and method of birth control if sexually active.
●● Systems review (SR) or review of systems (ROS)
Answer: A systems review is obtained through a logical sequence of
questions about the state of health of body systems, beginning with the
head and proceeding downward. The provider typically completes this
section of the medical history while conducting the physical
examination.
●● Allergy Documentation
Answer: Each medical practice has a policy on how to document a
patient's allergies. In a paper record, they typically are written in red ink
or identified by a colored sticker so that all healthcare workers can easily
see it. EHR systems have methods for including allergy information on
all pertinent screens in the patient's record.
●● Understanding and Communicating With Patients
