Which term describes a comprehensive assessment of a patient's medical history and physical examination findings?

• A. MDM
• B. Discharge instructions
• C. History and Physical
• D. Consultations

Answer: (C)

The concept being tested is the formal, comprehensive evaluation that documents a patient’s medical history and the findings from the physical examination. This is called a History and Physical.

A History and Physical includes the patient’s past medical history, current symptoms and problems, medications, allergies, social and family history, a thorough review of systems, and the clinician’s notes from the physical examination, often with an initial assessment and plan. It serves as the foundational record for understanding the patient’s health status at a particular visit.

Other terms describe different parts of care. Medical decision making focuses on the reasoning process and the complexity of diagnosing and choosing tests or treatments, not the full initial assessment. Discharge instructions are the guidance given to the patient when leaving care. Consultations are opinions obtained from other specialists.