Health assessment on a patient in a single clinic visit.

Full Answer Section

1. Family History (FH):
   • Health status of immediate family members (parents, siblings, children).
   • History of genetic or familial diseases.
2. Social History (SH):
   • Occupation, lifestyle, diet, exercise habits.
   • Tobacco, alcohol, and drug use.
   • Sexual history.
   • Living situation (alone, with family, etc.).
3. Review of Systems (ROS):
   • A systematic inquiry into all major organ systems to identify any abnormalities.
     • General
     • Skin
     • Head and neck
     • Eyes
     • Ears, nose, and throat
     • Cardiovascular
     • Respiratory
     • Gastrointestinal
     • Genitourinary
     • Musculoskeletal
     • Neurologic
     • Psychiatric
4. Physical Exam:
   • A comprehensive examination of the patient's body, including:
     • General appearance
     • Vital signs (temperature, pulse, respiration, blood pressure)
     • Head and neck
     • Eyes
     • Ears, nose, and throat
     • Cardiovascular
     • Respiratory
     • Abdomen
     • Musculoskeletal
     • Neurologic
     • Skin
5. Assessment:
   • A summary of the patient's condition, including:
     • Diagnosis or differential diagnoses.
     • Underlying causes.
     • Contributing factors.
6. Plan:

• Treatment plan, including:
  • Medications
  • Procedures
  • Follow-up appointments
  • Patient education

• Cultural Sensitivity: Be mindful of cultural differences and beliefs that may influence the patient's health beliefs and behaviors.
• Language Barriers: Use appropriate language interpretation services if needed.
• Time Management: Efficiently manage your time to ensure a thorough assessment within the allotted time frame.
• Documentation: Accurately and comprehensively document all findings and interventions in the patient's medical record.

Sample Answer

Essential Components of a Full Health Assessment

1. Patient Demographics:

   • Age, gender, race, ethnicity, occupation, marital status, and religion.
   • Contact information (address, phone number, email).
   • Insurance information.

2. Chief Complaint (CC):

   • The main reason for the patient's visit.
   • Onset, duration, location, severity, and associated symptoms.

3. History of Present Illness (HPI):

   • Detailed description of the CC, including:
     • When it started.
     • How it has progressed.
     • Any aggravating or alleviating factors.
     • Related symptoms.

4. Past Medical History (PMH):

   • Chronic conditions (e.g., diabetes, hypertension, heart disease).
   • Previous surgeries, hospitalizations, or injuries.
   • Allergies (drugs, food, environmental).
   • Immunizations.