An individual’s weight and body composition (proportion of fat and fat distribution) offer information about health status and may provide a clue to the presence of disease when out of balance. Nutrition is considered the science of food as it…
The mental status portion of the neurologic examination is a complex process. Mental status is the total expression of a person’s emotional responses, mood, cognitive functioning (ability to think, reason, and make judgments), and personality. A major focus of the…
The vital signs include assessment of temperature, pulse, respiration, and blood pressure. They are considered the baseline indicators of a patient’s health status. Pain assessment is considered the fifth vital sign. Pain is a subjective unpleasant symptom of many conditions…
After performing the history and physical examination, the healthcare clinician must organize, synthesize, and record the data along with the problems identified and the rationale for the diagnostic evaluation and plan of care. This cognitive effort goes well beyond simply…
Clinical reasoning is the process by which the information gathered from the history and physical examination is merged with clinical knowledge, experience, and the current best evidence to formulate the next steps in patient care—development of the diagnostic and management…
This chapter provides an overview of the techniques of inspection, palpation, percussion, and auscultation that are used throughout the physical examination. In addition, general use of the equipment for performing physical examination is discussed ( Box 3.1 ). Specific details…
This chapter discusses the development of relationships with patients and the building of histories or healthcare narratives. We write of it as “building” a history rather than “taking” one because you and your patient are involved in a joint effort,…
Achieving cultural competence is a learning process that requires self-awareness, reflective practice, and knowledge of core cultural issues. It involves recognizing one’s own culture, values, and biases and using effective patient-centered communication skills. A culturally competent healthcare provider adapts to…