Medical and Psychosocial History
A medical and psychosocial history, together with a physical exam and diagnostic tests, provide critical details used by your doctor to help form a potential diagnosis. The medical history will include a discussion about past medical and family history, current medical conditions and medications and a social history where details about marital status, offspring and hours on the job, for example, are documented.
Physical Exam
Physical examinations are part of any wellness or sick visits. The physical exam can vary greatly depending on the patient's requirements; however, a complete physical examination looks at everything from your appearance to specific systems.
A thorough physical exam summarized from wrongdiagnosis.com's article "What does your doctor do in a physical examination?" explains that a first step is to check your vital signs (temperature, pulse and blood pressure) and note weight and height. A visual examination usually follows and is used to look for any abnormalities that can be seen with the naked eye. Palpation, or pressing with the hands, is used to assess size, shape and location of any pain. Tapping or scraping a body part is called percussion and is used to determine organ size and density. Your doctor will listen to sounds produced by your heart, stomach and lungs with a stethoscope via a process called auscultation. Lastly, your ears, nose and throat, will be inspected both inside and out using an otoscope.
Diagnostic Tests
A comprehensive health assessment also involves thorough diagnostic testing, like that described by Dr. Eric Braverman at PATH Medical, a New York practice that specializes in executive health assessments. The extent of the testing will depend on the reason for your visit and the results of the physical examination performed by your doctor.
Blood and urine samples are generally taken first as these tests usually require fasting to ensure an empty stomach. Tests that follow include an electrocardiogram to examine the heart, a pulmonary function test to test lung capacity, and ultrasound to examine other internal organs. Bone density is measured using a dual energy X-ray absorptiometry, or DEXA test, and brain function can be evaluated with a BEAM brain test, a computerized electroencephalogram and a host of other psychological paper-and-pencil testing.
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