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1、CHAPTERAnOverviewofAnOverviewofPhysicalExaminationPhysicalExaminationandHistoryTakingandHistoryTaking11Thetechniquesofphysicalexaminationandhistorytakingthatyouareabouttolearnembodytime-honoredskillsofhealingandpatientcare.Yourabil-itytogatherasensitiveandnuancedhistory
2、andtoperformathoroughandaccurateexaminationdeepensyourpatientrelationships,focusesyourpatientassessment,andsetsthedirectionofyourclinicalthinking.Thequalityofyourhistoryandphysicalexaminationgovernsyournextstepswiththepatientandguidesyourchoicesfromtheinitiallybewilderi
3、ngarrayofsecondarytestingandtechnology.Overthecourseofbecominganaccomplishedclinician,youwillpolishtheseimportantrelationalandclinicalskillsforalifetime.Asyouentertherealmofpatientassessment,youbeginintegratingthees-sentialelementsofclinicalcare:empathiclistening;theabi
4、litytointerviewpatientsofallages,moods,andbackgrounds;thetechniquesforexaminingthedifferentbodysystems;and,finally,theprocessofclinicalreasoning.Yourexperiencewithhistorytakingandphysicalexaminationwillgrowandexpand,andthestepsofclinicalreasoningwillsoonbeginwiththefirstm
5、omentsofthepatientencounter:identifyingproblemsymptomsandabnormalfind-ings;linkingfindingstoanunderlyingprocessofpathophysiologyorpsycho-pathology;andestablishingandtestingasetofexplanatoryhypotheses.Work-ingthroughthesestepswillrevealthemultifacetedprofileofthepatientbefo
6、reyou.Paradoxically,theveryskillsthatallowyoutoassessallpatientsalsoshapetheimageoftheuniquehumanbeingentrustedtoyourcare.ClinicalAssessment:TheRoadAheadThischapterprovidesaroadmaptoclinicalproficiencyinthreecriticalareas:thehealthhistory,thephysicalexamination,andthewri
7、ttenrecord,or“write-up.”Itdescribesthecomponentsofthehealthhistoryandhowtoor-ganizethepatient’sstory;itgivesanapproachandoverviewtothephysicalex-aminationandsuggestsasequenceforensuringpatientcomfort;and,finally,itprovidesanexampleofthewrittenrecord,showingdocumentationo
8、ffind-ingsfromasamplepatienthistoryandphysicalexamination.Bystudyingthesubsequentchaptersofthebookandperfecting
