What Should Be Included in a Physical Examination iHuman Patients Guide?
A physical examination in the iHuman Patients Guide should include a targeted, systematic assessment of the patient driven by the history of the present illness, encompassing vital signs, mental status, a general survey, and focused body system examinations — all documented with pertinent positive and negative findings in the iHuman Electronic Health Record (EHR). The physical examination in iHuman is the objective component of the patient encounter and should be structured, efficient, and clinically relevant to the chief complaint rather than exhaustive, with each exam component selected to help refine the student’s differential diagnosis.
The Role of the Physical Examination in iHuman
The physical examination is the next component of patient evaluation after history-taking. Students will select and perform various exams, as driven by the history of the present illness and any supportive information. While it is important to be comprehensive, the goal is to perform a targeted and efficient physical examination by selecting only those exam components relevant to, and otherwise suggested by, the patient’s presentation. USA Nursing Papers
Physical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient’s history and pathophysiology. The physical examination, thoughtfully performed, should yield approximately 20% of the data necessary for patient diagnosis and management. kaplan.com This principle is built directly into the iHuman framework — the platform rewards efficiency, not exhaustiveness.
Vital Signs
Vital signs are the mandatory starting point for every iHuman physical examination. Students must open and view the patient’s record to receive credit for obtaining vital signs. Studocu Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age- or condition-appropriate pain scale. Nursingwritingservices In iHuman, failing to access vital signs through the EHR Current Visit tab means the student will not receive credit for this essential component, regardless of how well the rest of the examination is conducted.
After obtaining vital signs, students should obtain and analyze them carefully, initiating emergency assistance as needed. Students should also evaluate for the presence of pain or other types of discomfort. If pain or discomfort is present, a comprehensive pain assessment using the PQRSTU framework should be performed. Ihumanassignmenthelp
Mental Status and General Survey
The general survey includes the overall impression of the client, mental status exam, and vital signs. Kaplan Test Prep In iHuman, the mental status and general exam must always be completed as part of the foundational physical examination. The iHuman problem list should be inclusive of all key findings throughout all aspects of the physical examination, including vital signs, mental status, and the general exam. USA Nursing Papers
The standard format for documenting the Mental Status Examination should cover appearance, behavior, mood and affect, speech, thought process and content, perceptual disturbances, cognition, insight, and judgment. Assessment of mental status may not occur routinely in all clinical settings, but in the hospital setting the nurse completes a full mental status assessment on admission and any time during the individual’s hospital stay to establish if a change in mental state has occurred. Nursingwritinghelpers
A routine neurological exam usually starts by assessing the patient’s mental status followed by evaluation of sensory function and motor function. Nurses begin assessing a patient’s overall neurological status by observing their general appearance, posture, ability to walk, and personal hygiene in the first few minutes of nurse-patient interaction. AceMyHomework
Focused Body System Examinations
Following the general survey and vital signs, the physical examination in iHuman moves into focused body system assessments. Students can perform a limit of 40 exams and should always listen to the heart and lungs. Acemynursingpapers The cardiovascular and respiratory systems are universally required components regardless of the chief complaint, as abnormal cardiac and pulmonary findings frequently intersect with the clinical presentation.
A comprehensive guide to patient assessment identifies that the physical examination begins the moment you meet the patient with the general survey, then proceeds through body systems including the integumentary system, head and neck, cardiovascular, respiratory, gastrointestinal, musculoskeletal, and neurological systems. These two components — history and physical — are inextricably linked. A finding on physical examination prompts deeper questioning in the history, and a symptom described in the history directs a more focused physical exam. OnlineNursingPapers
Inspection, Palpation, Percussion, and Auscultation
The four basic assessment techniques used throughout the physical examination are inspection, palpation, percussion, and auscultation. Inspection involves using the senses of vision, smell, and hearing to observe and detect normal or abnormal findings. Palpation consists of using parts of the hand to touch and feel for texture, temperature, moisture, mobility, consistency, strength of pulses, size, shape, and degree of tenderness. Percussion involves tapping body parts to produce sound waves that enable the examiner to assess underlying structures. Auscultation involves the use of a stethoscope to listen for heart sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract. Kaplan Test Prep
In iHuman, these four techniques are embedded within each selectable physical exam component. Students must activate the appropriate technique for each body system and document their findings accurately in the EHR.
Documentation of Physical Examination Findings
Information gathered during the physical examination by inspection, palpation, auscultation, and percussion should be documented under physical exam. Students should limit physical exam documentation to findings pertinent to the focused assessment based on the chief complaint. If unable to assess a pertinent body system, the student should write “Unable to assess.” Students should document pertinent positive and negative assessment findings separately and be detailed in their descriptions. Findings should be described in full — students should not use the abbreviation “WNL” (within normal limits). HealthySimulation.com
Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results. Objective data is obtained during the physical examination component of the assessment process. Kaplan
Adding Key Findings and Building the Problem List
Throughout the physical examination, students must actively populate the iHuman problem list. Key findings may be added at any time during the history or physical exam by clicking the plus (+) sign. Key findings may be organized using the up and down arrows, and students will organize them further in the Assessment step. HealthySimulation.com
The iHuman problem list should include all key findings throughout all aspects of the physical examination, including vital signs, mental status, and the general exam. Pertinent negatives, while clinically important, should not be listed on the problem list. USA Nursing Papers Instead, pertinent negatives belong in the EHR documentation under the physical exam section.
Connecting the Physical Examination to the Differential Diagnosis
Students can achieve greater efficiency in conducting the history and physical examination by developing the differential diagnosis as they go. The questions posed to the patient and the exam components selected will, in turn, help to further characterize and refine the differential diagnosis. USA Nursing Papers
The physical examination should be tailored to the purpose of visit, patient history, and allotted time in a focused assessment by body systems. In some cases, a diagnosis is possible on the basis of the physical examination alone, but the physical examination is typically used alongside the patient history to determine the differential diagnoses and further diagnostic and management steps. Nursemygrade
In summary, a complete and well-executed physical examination in iHuman requires vital signs, mental status, a general survey, focused body system assessments using the four examination techniques, and thorough EHR documentation of all pertinent positive and negative findings — all structured around the patient’s chief complaint and designed to systematically support or refute each working hypothesis on the student’s differential diagnosis.
References
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iHumanHelp.com. (2024, October 22). iHuman step by step instructions: History, physical examination, and diagnosis. https://ihumanhelp.com/2024/10/22/ihuman-step-by-step-instructions-history-physical-examination-and-diagnosis/
Walker, H. K., Hall, W. D., & Hurst, J. W. (Eds.). (1990). The physical examination. In Clinical methods: The history, physical, and laboratory examinations (3rd ed.). Butterworths. https://www.ncbi.nlm.nih.gov/books/NBK361/
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AMBOSS. (2024). Physical examination. https://www.amboss.com/us/knowledge/physical-examination/