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Done for several reasons first it presents the actual

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done for several reasons. First, it presents the actualvalues and allows readers of the H&P to formulatetheir own conclusions regarding the meaning of thevalues. Second, it documents the baseline values thatthe patient has as a reference point.ird, it saves timefor other readers to have the values listed rather thanhaving to look them up.Problem List, Assessment, andDifferential DiagnosisOnce you have documented all the elements ofthe H&P and results of diagnostic studies, you canevaluate all the information to identify the patient’sproblems. Use a numbered list that includes the dateof onset and whether a particular problem is activeor inactive. List the most severe problems first. Afterthe initial list is generated, new problems are listedchronologically.Make an assessment of each current problem.isentails a brief evaluation of the problem with differentialdiagnosis.is is a very important component of thecomprehensive H&P because it demonstrates yourjudgment and documents the medical decision-makingthat you considered regarding each problem.Plan of CareDocument any additional studies or workup needed,referrals or consultations needed, pharmacological man-agement, nonpharmacological or other management,patient education, and disposition such as “return toclinic” or “admit to the hospital.”ere are different ways that you can document theassessment and plan. Sometimes you will see assess-ment and plan documented as numbered or bulletedlists under separate headings, or you may see themtogether. Example 2.1 demonstrates the differencein these approaches. Either is acceptable and whichis used depends largely on health-care provider pref-erence and whether documentation is paper-basedor EMR-based.EXAMPLE 2.1Assessment:1.Cough: nonproductive and no signs or symptomsof infectious process. Recently started anangiotensin-converting enzyme (ACE) inhibitor,so may be side effect of medication.
Chapter 2e Comprehensive History and Physical Examination|33Copyright © 2019 by F. A. Davis Company. All rights reserved.Comprehensive History and Physical ExaminationPATIENT NAME:William R. JensenAGE:67SEX:MaleDOB:March 30, 19XXCHIEF COMPLAINT:“I’ve been feeling tired and I have lost some weight.”HISTORY OF PRESENT ILLNESS:This is a 67-year-old Caucasian male who is a new patient to this practice, having recentlymoved to the area. Mr. Jensen complains of “feeling tired.” He states this has been going on for several months. He first noticed thiswhen he and his wife went on a short hike that he had previously completed without difficulty. Initially, he thought he had a mild“flu-like illness” that would account for his fatigue. The fatigue is worsened with exertional activity. Other than rest, he has notidentified any alleviating factors. Mr. Jensen states that he has lost approximately 10 pounds in the past 2 months without anychange in his diet or activity level. His appetite is good, and he has not intentionally decreased his food intake or avoided any type

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Health care provider, F A Davis Company

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