Final answer:
The part of the patient assessment process that involves obtaining in-depth information about the patient's chief complaint and medical history is called history taking. Additional tests and treatments are recommended based on the findings from the history, physical examination, and diagnostic test results. The process requires skillful information gathering and analysis to determine the cause of the patient's complaint.
Step-by-step explanation:
Understanding Patient Assessment
The part of the patient assessment process that focuses on obtaining additional information about the patient's chief complaint and any medical problems he/she may have is known as the history taking or medical interview. This step goes beyond the initial general assessment and involves gathering detailed information from the patient or other sources about their current condition and medical history. This would include an inquiry into the patient's orientation, past medical history, and a review of symptoms to better understand the chief complaint.
To determine the additional tests for a patient like Carli, facing severe gastrointestinal distress, the doctor may consider conducting diagnostic imaging, such as a CT scan, or laboratory tests, like blood work and stool analysis, to identify the cause. The choice of tests depends on the initial findings and the suspected diagnosis after history taking and physical examination.
Recommending treatment based on clinical findings involves integrating the history and examination with the results of any tests performed. For example, if John's, fever, headache, chest pain, coughing, shortness of breath, nausea, and diarrhea are indicative of a respiratory infection superimposed on his chronic conditions of asthma and diabetes, the doctor may recommend antibiotics, fever reducers, and specific measures to manage his asthma and diabetes during the course of the infection.
Furthermore, the accuracy of the patient assessment relies on the medical professional's skill in gathering information from different sources, conducting a root cause analysis, and incorporating expert knowledge found in the medical literature or from other healthcare professionals.