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In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
After all of the important history questions have been asked, a focused physical exam (meaning one that only involves what is relevant to the chief concern) is usually done. Based on the information obtained from the H&P, lab and imaging tests are ordered and medical or surgical treatment is administered as necessary.
Different sources include different questions to be asked while conducting a PMH, but in general, they include the following: General state of health: e.g. excellent, good, fair, poor. Note any significant change from previous state. Past illnesses: e.g. cancer, heart disease, hypertension, diabetes.
Health & physical assessment in nursing. Boston: Pearson. ISBN 978-0-13-387640-6. Bates, Barbara (1995). A pocket guide to physical examination and history taking. Philadelphia: Lippincott. ISBN 9780397550579. Habich, Michele, and MariJo Letizia. 2015. "Pediatric Pain Assessment In the Emergency Department: A Nursing Evidence-Based Practice ...
Pages in category "Physical examination" The following 70 pages are in this category, out of 70 total. This list may not reflect recent changes. ...
An abdominal examination may be performed because the physician suspects a disease of the organs inside the abdominal cavity (including the liver, spleen, large or small intestines), or simply as a part of a complete physical examination for other conditions. In a complete physical examination, the abdominal exam classically follows the ...
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).