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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.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
Physical examination The physical examination is the recording of observations of the patient. This includes the vital signs, muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing. Assessment and plan
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).
In forensic science, questioned document examination (QDE) is the examination of documents potentially disputed in a court of law. Its primary purpose is to provide evidence about a suspicious or questionable document using scientific processes and methods.
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.
Tests specific to HEENT examination Eyes: eye examination and acuity (including ophthalmoscope) Ears: hearing examination and evaluation of tympanic membrane (TM) (otoscope used in evaluation of ears, nose, and mouth) A neurological examination is usually considered separate from the HEENT evaluation, although there can be some overlap in some ...