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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]
The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.
Health assessment has been separated by authors from physical assessment to include the focus on health occurring on a continuum as a fundamental teaching. [8] In the healthcare industry it is understood health occurs on a continuum, so the term used is assessment but may be preference by the speciality's focus such as nursing, physical therapy, etc.
A medical sign is an objective observable indication of a disease, injury, or medical condition that may be detected during a physical examination. [7] These signs may be visible, such as a rash or bruise, or otherwise detectable such as by using a stethoscope or taking blood pressure. Medical signs, along with symptoms, help in forming a ...
Eponymous medical signs are those that are named after a person or persons, usually the physicians who first described them, but occasionally named after a famous patient. This list includes other eponymous entities of diagnostic significance; i.e. tests, reflexes, etc.
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical history, [1] but not deeper investigation such as neuroimaging.
Other assessment tools may focus on a specific aspect of the patient's care. For example, the Waterlow score and the Braden scale deals with a patient's risk of developing a Pressure ulcer (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various pain scales exist to assess the "fifth vital sign".
see Physical examination#Example: labs and diagnostics studies "none" May cover studies performed at an outside hospital, during prior admissions, or in the ER before the current admission. assessment and plan (A&P) "Pt is a 30 yo female..." Assessment and plan are very closely related, and are often reported in a single section.