文档介绍：CHAPTER
AnAn OverviewOverview ofof
PhysicalPhysical ExaminationExamination
andand HistoryHistory TakingTaking 11
The techniques of physical examination and history taking that you are about
to learn embody time-honored skills of healing and patient care. Your abil-
ity to gather a sensitive and nuanced history and to perform a thorough and
accurate examination deepens your patient relationships, focuses your patient
assessment, and sets the direction of your clinical thinking. The quality of your
history and physical examination governs your next steps with the patient and
guides your choices from the initially bewildering array of secondary testing
and technology. Over the course of ing an plished clinician, you
will polish these important relational and clinical skills for a lifetime.
As you enter the realm of patient assessment, you begin integrating the es-
sential elements of clinical care: empathic listening; the ability to interview
patients of all ages, moods, and backgrounds; the techniques for examining
the different body systems; and, finally, the process of clinical reasoning. Your
experience with history taking and physical examination will grow and expand,
and the steps of clinical reasoning will soon begin with the first moments of
the patient encounter: identifying problem symptoms and abnormal find-
ings; linking findings to an underlying process of pathophysiology or psycho-
pathology; and establishing and testing a set of explanatory hypotheses. Work-
ing through these steps will reveal the multifaceted profile of the patient before
you. Paradoxically, the very skills that allow you to assess all patients also shape
the image of the unique human being entrusted to your care.
Clinical Assessment: The Road Ahead
This chapter provides a road map to clinical proficiency in three critical areas:
the health history, the physical examination, and the written record, or
“write-up.” It describes ponents of the health history and ho