History Taking and Physical Examination
- Identify elements of, and need for, comprehensive and focused interviews appropriate for the age and gender of the patient, reason for visit, urgency of the problem, and patient’s ability to provide history.
- Recognize and interpret pertinent historical information.
- Identify history commonly associated with specific medical conditions.
- Identify elements of, and need for, comprehensive and focused physical examinations appropriate for the age and gender of the patient, reason for visit, urgency of the problem and patient’s ability to participate in the examination.
- Identify required techniques in the physical examination.
- Recognize and interpret* pertinent physical examination findings when presented in written or illustrated form.
- Determine the need for other resources (e.g., past records, consultation, other members of the health care team) to expand knowledge of the patient’s history.
- Interpret history and physical examination findings in order to differentiate one disorder from another.
“Interpret” means to determine if normal or abnormal, or to determine the meaning of the finding relative to pathophysiologic processes and disease.
- Demonstrate knowledge of appropriate patient and family education related to laboratory and diagnostic studies.
- Identify techniques and potential complications for common diagnostic procedures.
- Select the appropriate initial and subsequent laboratory and diagnostic studies based upon initial impressions determined from the history and physical examination or germane to the health-screening situation.
- Identify the indications for specific laboratory and diagnostic studies.
- Identify risks associated with laboratory and diagnostic studies.
- Recognize normal and abnormal values for routine laboratory and diagnostic studies.
- Interpret the results of routine laboratory and diagnostic studies.
- Select appropriate laboratory and diagnostic testing by considering and evaluating the cost, probable yield, invasiveness, and contraindications of laboratory and diagnostic studies.
- Determine if and when additional diagnostic studies are required.
- Identify laboratory and clinical studies considered to be the best for the diagnosis of certain conditions.
- Determine a differential diagnosis based upon historical information, physical examination findings, and laboratory and diagnostic study findings.
- Select the most likely diagnosis based upon historical information, physical examination findings, and laboratory and diagnostic study findings.
- Determine appropriate counseling, as well as patient and family education, related to preventable diseases, communicable diseases, immunization schedules, and healthy lifestyles.
- Determine the appropriate history and physical examination in screening an asymptomatic patient during well-care visit based on age.
- Recognize risk factors for conditions amenable to prevention or detection in an asymptomatic individual.
- Recognize the impact of stress on health and the psychological manifestations of illness and injury.
- Recognize the effects of aging and family roles on health.
- Recognize the impact of environmental and occupational exposures on health.
- Recognize the signs and symptoms of abuse and neglect and the indications for intervention and referral.
- Identify common barriers to care.
- Identify the risks and benefits of immunizations.
- Select the appropriate laboratory and diagnostic screening studies and identify normal ranges.
- Identify growth and human development milestones.
- Match anticipatory guidance to the appropriate age level and to the sequalae it intends to prevent.
- Select the application or technique required for common clinical interventions. Identify appropriate monitoring for patients after interventions, including checking for compliance, adverse events, and effectiveness.
- Recognize appropriate counseling and patient and family education related to clinical interventions.
- Identify proper referral strategies for patients to other services for clinical intervention as appropriate.
- Determine appropriate follow-up from referrals.
- Select a clinical intervention plan that is consistent with the working diagnosis. Prioritize clinical interventions in emergent, acute, and chronic care situations.
- Evaluate severity of patient condition in terms of need for medical and /or surgical referral, admission to the hospital or other appropriate setting.
- Determine appropriate surgical treatment and post-surgical/post-procedural management.
- Identify potential complications of specific clinical interventions and procedures.
- Recognize appropriate plans for patient discharge, as well as appropriate medical, surgical, and rehabilitation follow-up.
- Select non-pharmacologic modalities (e.g., physical therapy, surgery, counseling) to integrate into patient management plans.
- Identify appropriate counseling and patient and family education related to a clinical therapeutic agent including drug-drug interactions.
- Identify key safety factors related to the administration of medications (oral, topical, sublingual, subcutaneous, intramuscular, rectal, otologic, vaginal, and ophthalmic).
- Recognize appropriate plans to monitor pharmacotherapy, checking for compliance, side effects, adverse reactions, and effectiveness.
- Select a clinical therapeutic plan that considers the cost, efficacy, possible adverse reactions, contraindications, and drug interactions for medications selected.
- Recognize the pharmacokinetic properties, indications, and contraindications for the use of pharmacologic agents. Apply this knowledge to the safe and effective selection and administration of medications.
- Identify side effects, adverse reactions, contraindications, precautions, therapeutic effects, and dosing of the major classes of clinically important drugs and commonly used medications.
- Identify the risks for, and signs and symptoms of, drug interactions resulting from poly-pharmacy in the therapeutic regimen.
- Recognize the appropriate actions to take in response to acute, specific drug toxicity.
- Modify therapeutic regimen within the context of continuing care.
- Apply basic sciences (anatomy, physiology, microbiology, genetics, etc.) to the diagnosis and management of specific medical conditions.
- Recognize associations of disease conditions and complications through application of scientific concepts.
- Demonstrate understanding of concepts of public health in the management of the population’s and an individual patient’s health and well-being, as well as disease. Identify underlying processes or pathways responsible for a specific condition or disease.