Talk intently, to the seat of wisdom, as life resembles grace.
Achieve peace within a fragile countenance.
Seek the comfort of the placid hour know the other side of the ﬂesh’s frame.
After a dialogue is established, the patient assessment proceeds with obtaining a complete history and performing a physical examination. Both of these aspects of the assessment rely on good patient–physician interchange and attention to details. During the history and physical examination, risk factors that may require special attention should be identified.
These factors should be reviewed with the patient in developing a plan for her future care (see Chapter 8).
Depending on the setting—ambulatory office, inpatient hospitalization, or outpatient surgical center—record keeping is typically facilitated by forms or templates (either written or electronic), which provide prompts for important elements of the medical, family, and social history. Increasingly, electronic medical records are used in the office and hospital setting. One challenge is that paper and electronic records do not always “mesh,” and both paper and electronic records may be periodically unavailable. Efforts to develop patient-held medical records are not yet widely adopted.
History After the chief complaint and characteristics of the present illness are ascertained, the medical history of the patient should be obtained. It should include her complete medical and surgical history, her reproductive history (including menstrual and obstetric history), her current use of medications (including over-the-counter and complementary and alternative medications), and a thorough family and social history.
A technique for obtaining information about the present illness is presented in Table 1.5. The physician should consider which other members of the health care team might be helpful in completing the evaluation and providing care. Individuals who interact with the patient in the office—from the receptionists to medical assistants, nurses, advance practice nurses (nurse practitioners or nurse-midwives)—can contribute to the patient’s care and may provide additional information or insight or be appropriate clinicians for providing follow-up. In some teaching hospitals, residents or medical students may provide care and participate in an office setting. The role that each of these individuals plays in a given office or health care setting may not be apparent to the patient; care should be taken that each individual introduces her-or himself at the opening of the interaction and explains his or her role on the team. It may be necessary to discuss the roles and functions of each individual member of the team. In some cases, referral to a nutritionist, physical or occupational therapist, social worker, psychologist, psychiatrist, or sex counselor would be helpful. Referral to or consultations with these clinicians and with physicians in other specialty areas should be addressed as needed. The nature of the relationship between the obstetrician/gynecologist and the patient should be clarified. Some women have a primary clinician whom they rely on for primary care. Other women, particularly healthy women of reproductive age, consider their obstetrician/gynecologist their primary clinician. The individual physician’s comfort with this role should be discussed and clarified at the initial visit and revisited periodically as required in the course of care. These issues are covered in Section III, Preventative and Primary Care (see Chapters 8–13). Laboratory testing for routine care and high-risk factors is presented in Chapter 8.