Final introduction to health assessment.pptx

Final introduction to health assessment.pptx

1. Nursing Health Assessment

2. Course description The course is designed: to provide adequate level of knowledge and skills necessary for assessing the health status of the client. to perform physical examination in a systematic manner so as to determine the health status of individuals

3. Course contents Nursing Health Assessment- I Introduction to Health Assessment Assessment of Musculoskeletal system Examination of thorax and the lungs Health assessment of the integumentary system Nursing Health Assessment- II Assessment of cardiovascular system Assessment of Genitourinary system Assessment of nervous system

4. Course objectives General objective After completing this course, the student will be able to: assess the client using proper history taking, performing complete physical examination, identify actual & potential health problem of the patient.

5. Evaluation Individual assignment -----20% Exam -----------------------50 % Practical exam ----------------30%

6. Refe r ences Lynn S. Bickley, Peter G. Szilagyi, Richard M. Hoffman. Bates’ guide to physical examination and history taking.13 th edition. Philadelphia: Wolters Kluwer;2021 Carolyn Jarvis, Ann Eckhardt. Physical Examination & Health Assessment. 8 th edition. St. Louis, Missouri: Elsevier Inc;2020 Michael Glynn, William M. Drake. Hutchison’s Clinical Methods an integrated approach to clinical practice.24 th edition. St. Louis, Missouri: Elsevier Ltd;2018 Sharon Jensen. Nursing health assessment: a best practice approach. 3 rd edition. Philadelphia: Wolters Kluwer Health;2019

7. Refe r ences T. Heather Herdman, Shigemi Kamitsuru , Camila Lopes. NANDA International, Inc Nursing Diagnoses Definitions and Classification 2024–2026.13 th edition. New York: Thieme Medical Publishers Inc ;2024 Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr. Nursing care plans : guidelines for individualizing client care across the life span 10 th Edition. Philadelphia : F.A. Davis Company;2019 Howard K. Butcher, Gloria M. Bulechek , Joanne M. Dochterman,Cheryl M. Wagner. Nursing Interventions Classification (NIC). 7 th Edition. St. Louis, Missouri : Elsevier, Inc. ;2018

8. Session Objectives After completing this lesson, you will be able to: Describe the phases of the nursing process. Identify major characteristics of the nursing process. Compare directive and nondirective approaches to interviewing. Contrast various frameworks used for nursing assessment. Compare nursing diagnoses, medical diagnoses, an collaborative problems.

9. Session Objectives Describe various formats for writing nursing diagnoses. List guidelines for writing a nursing diagnosis statement. Identify activities that occur in the planning process. Identify factors that the nurse must consider when setting priorities. State the purposes of establishing client goals or desired outcomes. Identify guidelines for writing goals or desired outcomes.

10. Session Objectives Describe the process of selecting and choosing nursing interventions. Explain how implementing relates to other phases of the nursing process. Identify guidelines for implementing nursing interventions. Explain how evaluating relates to other phases of the nursing process. Describe five components of the evaluation process. Describe the steps involved in reviewing and modifying the client’s care plan.

11. Int r oduction to Nursing He a lth Asse s sment Learn i ng Objecti v es At the end of this se s s i on the students w i l l be able De f i n e hea l th as s es s m ent List purposes of health assessment Identify the steps of health assessment Differentiate among the two type of data: subjective and objective Compare the four types of health assessment List t h e compo n en t s of t he co m pr e he n s i ve h i s t ory ta k i n g Id e n t ify t h e tec h n i q u es of s k i l l ed i n ter v iew

12. A systematic process of collecting, organizing, analyzing and validating of data about the client’s health status is the systematic and continuous collection, organization, validation, and documentation of data (information) Assessment Data Obtained From History Physical examination Laboratory & other diagnostic tests

13. Purpose of Health Assessment Collect physiologic, psychological, sociocultural, developmental & spiritual data about the client Identify actual and potential health problems

14. Steps of health assessment has four major steps Collection of subjective data Collection of objective data Validation of data Documentation of data

15. Collection of subjective data Subjective data , also referred to as symptoms or covert data , Sensations or symptoms (e.g., pain), feelings (e.g., happiness, sadness), perceptions, beliefs, values, and personal information that can be elicited and verified only by the client Subjective data- what the person says about him/herself during history taking Example - Client states “I have had a rash on my ankle and leg for the last two weeks” A  symptom  is any subjective evidence of disease

16. Collection of objective data Objective data , also referred to as signs or overt data Obtained by general observation, using four physical examination techniques(inspection, palpation, percussion &auscultation) and client’s medical record Objective data- what you observe by inspecting, percussing, palpation & auscultating during the physical examination Example - You observe that a client has a bright red rash on the dorsal side of the foot A  sign  is any objective evidence of disease

17. Comparing subjective and objective data Subjective data Objective data Description Data elicited and verified by the client Data directly or indirectly observed through measurement Sources Client Observations and physical assessment findings Documentation of assessments made in client record Methods used to obtain data Client interview Observation and physical examination Skills needed to obtain data Interview and therapeutic–communication skills Listening skills Inspection Palpation Percussion Auscultation Examples I have a headache I am not hungry BP 180/100, apical pulse 80 and irregular X-ray film reveals fractured pelvis

18. Rest and digest G is a 54-year-old hairdresser who reports pressure over her left chest “like an elephant sitting there,” which goes into her left neck and arm. G is a white male, pleasant and cooperative. Blood pressure 160/80, heart rate 96 and regular, respiratory rate 24, afebrile. What are the symptoms (subjective data)? What are the signs (objective data)?

19. Validating of data Validation is the act of “double-checking” or verifying data to confirm that it is accurate and factual. Is a crucial part of assessment that often occurs along with collection of subjective and objective data Purpose of validation Confirming or verifying that the subjective and objective data are reliable & accurate to prevent documentation of inaccurate data

20. Validating of data… Methods of validation: Recheck your own data through a repeat assessment Clarify data by asking additional questions Verifying the data with another health care professional Compare your objective findings with your subjective findings to uncover discrepancies

21. Documentation of data Thorough and accurate documentation is vital to ensure valid conclusions are made when the data are analyzed Purposes of documentation Promote effective communication among health team members Provide health care team with a database that becomes foundation for care of client Identify health problems, formulate nursing diagnoses, plan immediate and ongoing interventions

22. Documentation of data…. Methods of documentation Electronic health records (EHRs) Paper based

23. Types of Health Assessment Four basic types of assessment -depending on the clinical situation Initial ass e ssment Focused or problem-center ass e ssment T ime laps e d ass e ssment Emergency a ss e ssment

24. Initial assessment Performed at the time the patient enters the health care facility. Broad and leads us to a center of our diagnosis The aim of initial assessment is collection of data concerning actual or potential dysfunction

25. Focused Assessment For limited or short-term problems (seeking health care) Collect “mini” database, smaller scope and more focused than complete database Concerns mainly one problem or one body system

26. Time lapsed assessment It is the final assessment done after a period of time This assessment is focused type. Its aim is comparing the patient’s current status to baseline data obtained previously after a period of time

27. Emergency assessment Urgent-rapid collection of crucial data that is compiled with lifesaving measures Diagnosis must be swift & sure Once the person has been stabilized, a complete database can be compiled If the patient is un responsive, health care providers may need to rely on family & friends

28. Types of Assessment

29. Data collection methods Interview Physical examination Laboratory investigation Imaging 30

30. Interview Client -clinician interaction where by the clinician asks and the client answers. Phases of an interview Preparatory phase Introduction Working phase Termination 31

31. Preparatory phase First step to be practiced. Ensure environment is conducive Arrange seating 32

32. Introduction introduces your self Identifies purpose of interview Ensure confidentiality/privacy

33. Working Nurse gathers information Excellent communication skills such as active listening , Eye contact , Open-ended questions etc. should be practiced.

34. Termination Inform patient when nearing end of interview Ensure patient knows what will happen with the information. Offers patient chance to add anything

35. Purpose of an interview To establish a trusting relationship b/n the nurse and the client. Develop understanding about the patient condition. Helps the patient feel understood. Guides on which body parts or systems to focus during physical examination. To induce immediate psycho-logic therapy.

36. Skilled Interviewing Techniques Active or attentive listening Guided questioning Empathic responses Summarization Transitions Partnering Validation Empowering the patient Reassurance Appropriate verbal communication Appropriate nonverbal communication 37

37. 1. Active or Attentive Listening Active listening or attentive listening lies at the heart of the patient interview. It means carefully attending to what the patient is communicating, connecting to the patient’s emotional state, and using verbal and nonverbal skills to encourage the patient to expand on his or her feelings and concerns. Focus on what the patient is telling you, both verbally and nonverbally. Sometimes one’s body language tells a different story from one’s words.

38. 2. Guided Questioning There are several ways to elicit more information without changing the flow of the patient’s story. Techniques of Guided Questioning Moving from open-ended to focused questions Using questioning that elicits a graded response Asking a series of questions, one at a time Offering multiple choices for answers Clarifying what the patient means Encouraging with continuers Using echoing/repetition

39. Moving from Open-Ended to Focused Questions Your questions should flow from general to specific . Start with the most general questions like, “How can I help?” or “What brings you in today?” Then move to still open, but more focused , questions like, “Can you tell me more about what happened when you took the medicine?” Then pose closed questions like, “Did the new medicine cause any problems?”

40. Guided questioning

41. Moving from Open-Ended to Focused Questions… Avoid leading questions that already contain an answer or suggested response like: “Has your pain been improving?” or “You don’t have any blood in your stools, do you?” If you ask, “Is your pain like a pressure?” and the patient answers yes, the patient’s response is truncated instead of including details about what he or she experienced. Adopt the more neutral “Please describe your pain.”

42. Questioning That Elicits a Graded Response Ask questions that require a graded response rather than a yes-no answer. “How many steps can you climb before you get short of breath?” is better than “Do you get short of breath climbing stairs?

43. Asking a Series of Questions, One at a Time Be sure to ask one question at a time. “Any tuberculosis, diabetes, asthma, heart condition, or high blood pressure in the family?” may prompt “No” out of sheer confusion. Try “Do you have any of the following problems?” Be sure to pause and establish eye contact as you list each problem.

44. Offering Multiple Choices for Answers Sometimes, patients need help in describing their symptoms. To minimize bias, offer multiple-choice answers: “Which of the following words best describes your pain: aching, sharp, pressing, burning, shooting, or something else?”

45. Clarifying What the Patient Means Taking time for clarification reassures the patient that you want to understand his or her story and builds your therapeutic relationship. Sometimes the patient’s history is difficult to understand. It is better to acknowledge confusion than to act like the story makes sense. To understand what the patient means, you need to request clarification, as in “You said you were behaving just like your mother. What did you mean?”

46. Encouraging with Continuers Without even speaking, you can use posture and gestures (nonverbal encouragements) or words (neutral utterances) to encourage the patient to say more. Ex Pausing and nodding your head remaining silent, yet attentive and relaxed Leaning forward making eye contact using phrases like “Uh-huh,” or “Go on,” or “I’m listening”

47. Echoing (Repetition) Simply repeating the patient’s last words, or echoing, encourages the patient to elaborate on details and feelings. Echoing also demonstrates careful listening and a subtle connection with the patient by using the same words. For example: Patient: “The pain got worse and began to spread.” (Pause) Response: “Spread?” (Pause) Patient: “Yes, it went to my shoulder and down my left arm to the fingers. It was so bad that I thought I was going to die.” (Pause) Response: “Going to die?” Patient: “Yes, it was just like the pain my father had when he had his heart attack, and I was afraid the same thing was happening to me.”

48. Empathic responses Empathy has been described as the capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner. Once the patient has shared these feelings, reply with understanding and acceptance. E.g. “I understand your problem” or it may be behavioral such as providing a piece of soft for a patient in tears.

49. Summarization Giving a capsule summary of the patient’s story during the course of the interview serves several purposes. It communicates that you have been listening carefully. It identifies what you know and what you don’t know. Ex “Now, let me make sure that I have the full story. You said you’ve had a cough for three days, that it’s especially bad at night, and that you have started to bring up yellow phlegm. You have not had a fever or felt short of breath” Following with an attentive pause or asking, “Anything else?” allows the patient to add other information and correct any misunderstandings.

50. Transitions Patients may be apprehensive during a healthcare visit. To put them more at ease, tell them when you are changing directions during the interview. Just like signs along the highway, “signposting” transitions help prepare patients for what comes next. As you move through the history and on to the physical examination, orient the patient with brief transitional phrases like “Now I’d like to ask some questions about your past health.” “Before we move on to reviewing all your medications, was there anything else about past health problems?” “Now I would like to examine you. I will step out for a few minutes. Please undress and put on this gown.”

51. Non-verbal Communication Communication that does not involve speech occurs continuously and provides important clues to feelings and emotions. Becoming more sensitive to nonverbal messages allows you to both: - to “read the patient” more effectively and - to send messages of your own.

52. Partnering When building rapport with patients, express your commitment to an ongoing relationship. Make patients feel that no matter what happens, you will continue to provide their care. Even as a student, especially in a hospital setting, this support can make a big difference.

53. Validation Another way to affirm the patient is to validate the legitimacy of his or her emotional experience. A patient caught in a car accident, even if uninjured, may still feel very distressed. Saying something like, “Your accident must have been terrifying. Car accidents are always unsettling because they remind us how vulnerable we are. Perhaps that explains why you still feel upset,” validates the patient’s response as legitimate and understandable

54. Empowering the Patient The clinician–patient relationship is inherently unequal. Patients have many reasons to feel vulnerable. They may be in pain or worried about a symptom. Empowering the Patient: Techniques for Sharing Power Evoke the patient’s perspective. Convey interest in the person, not just the problem. Follow the patient’s leads. Elicit and validate emotional content. Share information with the patient, especially at transition points during the visit. Make your clinical reasoning transparent to the patient. Reveal the limits of your knowledge.

55. Reassurance When you are talking with patients who are anxious or upset, it is tempting to reassure them. The first step to effective reassurance is identifying and accepting the patient’s feelings. The actual reassurance comes much later after you have completed the interview, the physical examination, and perhaps some laboratory studies. Reassurance is more appropriate when the patient feels that problems have been fully understood and are being addressed.

56. Appropriate verbal communication As a clinician, it is important that we are careful in what we say, but equally important we should also be cautious as to how we say things. The effectiveness of the clinical encounter rests on the use of appropriate language. This can also enhance patient rapport and lead to a satisfying clinician–patient relationship. Use Understandable Language u nderstandable language uses simple, recognizable and clear words. It is critical to use short sentences and words and only communicate essential information. Simple words avoid the use of medical jargon, abbreviations or any complex words or phrases. use Nonstigmatizing Language On occasion, one may unintentionally use words or phrases during the clinical interview which could be perceived by the patient as dehumanizing, perpetuate stigma, and tend to marginalize rather than support them. For example, avoid saying: “Do you still consider yourself a drug addict?” or “Are you wheelchair bound?” but instead say “Do you still consider yourself a person with an addiction to drugs?” or “Are you a person who uses a wheelchair daily?”

57. Appropriate nonverbal communication Just as you carefully observe the patient, the patient will be watching you. Consciously or not, you send messages through both your words and your behavior. Posture, gestures, eye contact, and tone of voice all convey the extent of your interest, attention, acceptance, and understanding Forms of Nonverbal Communication Body orientation toward and physical proximity to patient Gaze orientation (eye contact) toward patients Head nodding with facial animation Head nodding with gesture Posture Use of silence Use of touch

58. Approaches of Health Assessment The systems approach -(medical model) The functional health pattern (Gordon’s approach)

59. Functional heath pattern Health perception-health management Value-belief Coping-stress-tolerance Nutritional-metabolic Sexuality-reproductive Elimination Role-relationships Self-perception-self-concept Activity-exercise Sleep-rest Cognitive-perceptual

60. Medical/System approach Clinical tool that is used to collect and organize clinical data based on body systems. Components Socio-demographic data, source of referral, Source of history Chief complaints(c/c), History of present illness (HPI) History of past illness (HPI) , systemic review Personal and social history, Family history Physical examination (PE) System based examination

61. History taking It is a process by which information is gained by a clinician by asking specific questions to the patient with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient

62. I m p o r t a n c e o f Hi s t o r y T a k i ng O b t a ini n g a n ac c u r a te h i s t o ry i s the c riti c al f i r s t s t e p i n d e t e r m i n i n g t h e etiology o f a p a ti e n t 's illn e s s. Diagnosis in disease is based on Clinical history Physical Examination Investigations

63. A la r g e p e r c e n t a ge o f t h e time ( 70 % ) , y ou w i ll ac t u a ll y b e a ble m a k e a d i a g nos i s b a s e d on t h e h i s t ory a l on e .

64. Approach to history taking Your look is important- Your dressing

65. Approach to history taking Introduce your self and create a rapport

66. Approach to history taking En s u r e c onse n t ha s bee n g aine d . Mai n t ain pri v acy and digni t y . Ensure the patient is as comfortable as possible Summarise each stage of the history taking process. Involve the patient in the history taking process

67. Approach to history taking Be alert and pay full attention

68. Approach to history taking If i n a bad mood or di s trac t ed during history taking, yo u c a n end u p mak i n g a hi s t o r y rather t ha n t aki n g a h i s t o r y ” .

69. Components of the Comprehensive Health History Patient ’ s profile Chief complaint History of the present illness Past medical history Family history Socioeconomic history System Review

70. Patients profile Biographic data - name , age , sex, Religion, address, birthplace, ,relationship status, ethnic origin , Occupation S ource of history usually the patient , but can be a family member, caregiver or friend, or the clinical record Sample Statements: Patient herself, who seems reliable Patient's son, X, who seems reliable Mrs. R , interpreter for Y, who does not speak Tigirigna

71. Chief Complaint(s)/( C/c)- Main reason for which the patient is trying to seek medical help Record these complaints in the patients' own words in chronological order and with the duration. Make every attempt to quote the patient’s own words. Usually one, but could be more If there is more than one complaint, it should be written according to chronological order Simple & brief Sometimes patients have no overt complaints, in which case you should report their goals instead.

72. Chief Complaint(s)/( C/c)- How to ask for chief complaint? What brings your here? How can I help you? What seems to be the problem? Sample Statements: “Chest pain for 2 hours” “My stomach hurts and I feel awful.” “I have come for my regular checkup” I feel like an elephant is sitting on my chest.”

73. History of the present illness-HPI Elaborate on the chief complaint in detail a chronologic record of the reason for seeking care, from the time the symptom first started until now. The narrative should include onset of the problem setting in which it has developed Manifestations Any treatments.

74. Attributes of a symptom Location: Where is it? Does it radiate? Quality: What is it like? Quantity or severity: How bad is it? (For pain, ask for a rating on a scale of 1 to 10.) Timing (Onset, Duration, Frequency) When does it start? How long does it last? How often does it come?

75. Attributes of a symptom Setting : what was the person doing when the symptom started? Aggravating or Relieving Factors. Does anything make it better or worse? What makes the pain worse? Is it aggravated by weather, activity, food, medication, standing, fatigue, time of day, or season? What relieves it (e.g., rest, medication, or ice pack)? Associated manifestations; Other signs or symptoms that occur when the problem, symptom, or pain occur

76. History of the present illness-HPI… pertinent positives” and “pertinent negatives”- These designate the presence or absence of symptoms relevant to the differential diagnosis, which refers to the most likely diagnoses explaining the patient’s condition. A negative statement is equally important as a positive statement. E.g.- absence of cough in respiratory problem , absence of SOB in CVS illness, absence of paralysis in CNS disorder

77. OPQRST O nset P recipitating and P alliating factors Q uality R egion or R adiation S everity T iming or T emporal characteristics OLD CARTS O nset L ocation D uration C haracter A ggravating or A lleviating factors R adiation T iming S etting Mnemonics for Characterizing the Chief Complaint

78. Suggested Steps in Documenting the HPI Start with an opening statement Further characterize the chief complaint with attention to chronology of events Then describe accompanying symptoms and their pertinence, called pertinent positives Include absent symptoms and their pertinence, called pertinent positives Add information from other parts of the health history that are relevant

79. Opening Statement Opening statements for the health history documentation provide a foundation for the reader to begin to think of possible causes for the patient’s condition. Example MN is a 54-year-old female with a remote history of intermittent headaches who states that her “head has been aching for the past 3 months.” JM is a 48-year-old male with poorly controlled diabetes mellitus presenting with 3 days of fever.

80. Elaboration of Chief Complaint with Attention to Chronology In the HPI, the CC should be documented and well characterized by its attending attributes This section should be a chronologic account of events as well, so pay attention to the timing of symptoms One method to maintain clarity of the patient’s story is to anchor each event to a timeline or its chronology. For example: “Two days prior to hospitalization, the patient developed multiple episodes of watery non-bloody diarrhea followed a day later by two episodes of non-bloody vomiting

81. Ex. Elaboration of Chief Complaint She was in her usual good health until 3 months prior to consultation when she started experiencing episodes of headache. These episodes occur on both sides of the front of her head without any radiation. They are throbbing and mild to moderately severe in intensity (rated as 3 to 6 out of 10 in the 10-point pain scale). The headaches usually last 4–6 hours, started as one to two episodes a month but now average once a week. The episodes are usually related to stress. The headaches are relieved by sleep and placing a damp cool towel over her forehead. There is little relief from acetaminophen.

82. Example Pertinent Positive and Negative Symptoms MN has missed work on several occasions because of associated nausea and occasional vomiting during the episodes. There are no associated visual changes, motorsensory deficits, loss of consciousness, or paresthesia

83. Additional Pertinent Information Here you should note any additional facts pertinent to the CC, regardless of where they are typically documented For example, if your patient has a fever and cough whom you believe has pneumonia, you may want to include the patient’s smoking history in the HPI. For a patient with fever and weight loss whom you think may have tuberculosis possible close contact with persons with pulmonary TB.

84. She had headaches with nausea and vomiting beginning at age 15 years. These recurred throughout her mid-20s, then decreased to one every 2 or 3 months, and almost disappeared. She thinks her headaches may be like those in the past but wants to be sure because her mother. had a headache just before she died of a stroke. She is concerned because her headaches interfere with her work and make her irritable with her family. She reports increased pressure at work from a demanding supervisor as well as being worried about her daughter. She eats three meals a day and drinks three cups of coffee a day and tea at night. Due to the increasing frequency of the headaches, she decided to come to the clinic today.

85. HPI example .. The patient was apparently well 1 w e e k be f or e t h e a d m i ss i on when the p a t i e n t f e l l w hi l e g a r d eni ng a n d c u t hi s f oo t w it h a s t o n e . B y that eve n i ng , t h e f oo t b ec a me s w o ll e n a n d p a ti ent w a s un a b l e t o w a l k. N e x t d a y pa t i e n t a tt e nd e d a private clinic where t h e y g ave him s o me o r al medicines. The patient do e s n ’ t kn ow t h e n ame of the medicines given but says that he was told the medicine would suppress his leg pains .however T h e r e was no improvement in h i s c ond iti o n . T w o d a y s p r i o r t o a d mi ss i on in ACSH , t h e swelling in the foot s t a r t e d t o d i s c h a r ge p us. The r e i s h i g h f e v e r a n d r i go rs w it h n a u s ea a n d vo mit i n g.

86. Past medical History… All the illness in the past from infancy; list in chronological order. It should include childhood illnesses, adult illnesses and its four areas: medical, surgical, psychiatric, obstetric/gynecologic health information. Childhood illnesses- Include- measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, scarlet fever, and polio It should include childhood illnesses, adult illnesses and its four areas: medical, surgical, psychiatric, obstetric/gynecologic health information.

87. Past medical History… Adult Illnesses Medical (such as DM, HTN, hepatitis, asthma, HIV, information about hospitalizations); Surgical (include dates, indications, and types of operations); Obstetric/gynecologic (relate obstetric history, menstrual history, birth control, and sexual function); Psychiatric (include dates, diagnoses, hospitalizations, and treatments).

88. Past medical History… Health Maintenance- Immunizations , such as tetanus, pertussis , diphtheria, polio, measles, rubella,mumps , influenza , hepatitis B, Haemophilus influenza type b, and pneumococcal vaccines (these can usually be obtained from prior medical records),& Screening Tests , such as tuberculin tests, Pap smears, mammograms, stools for occult blood, and cholesterol tests, together with the results and the dates they were last performed.

89. Past medical History-documentation Childhood Illnesses : Measles, chickenpox. No scarlet fever or rheumatic fever. Adult Illnesses: Medical: Pyelonephritis, 2016, with fever and right flank pain; treated with ampicillin; no recurrence of infection. Last dental visit 2 years ago. Surgical: Tonsillectomy, age 6; appendectomy, age 13. Sutures for laceration, 2012, Ob/Gyn : G3P3 (3-0-0- 3), with normal vaginal deliveries. Three living children. Menarche age 12. Last menses 6 months ago. Psychiatric : None. Health Maintenance : Immunizations: Age-appropriate immunizations up to date Screening tests: Last Pap smear, 2018, normal. Mammograms, 2019, normal

90. Family History Review each of the following conditions and record if they are present or absent in the family: Hypertension , coronary artery disease , ↑ cholesterol levels, stroke, diabetes, thyroid , renal disease, cancer (specify type), arthritis, TB, asthma or lung disease , headache, seizure disorder, mental illness, suicide, alcohol or drug addiction , and allergies, as well as symptoms reported by the patient.

91. Family History documentation Father died at age 43 years in a train accident. Mother died at age 67 years from stroke; had varicose veins, headaches. One brother, age 61 years, with hypertension, otherwise well; one brother, age 58 years, well except for mild arthritis; one sister—died in infancy of unknown cause. Husband died at age 54 of heart attack. Daughter, age 33 years, with migraine headaches, otherwise well; son, age 31 years, with headaches; son, age 27 years, well. No family history of diabetes, heart or kidney disease, cancer, epilepsy, or mental illness.

92. personal and social History Captures the patient’s personality and interests, sources of support, coping style, strengths, and fears. It should include: Occupation Home situation; Sources of stress, both recent and long-term; Important life experiences, such as military service, job history, financial situation, and retirement; Smoking history - amount, duration and type. Drinking history - amount, duration and type. family social support

93. Personal & social Hx … Also conveys lifestyle habits that promote health or create risk such as exercise and diet . Frequency of exercise Usual daily food intake, Dietary supplements or restrictions, and use of coffee, tea, and other caffeine-containing beverages.

94. Personal & social Hx … documents Born and raised in Lx, finished high school, married at age 19 years. Worked as a salesclerk for 2 years, then moved with her husband to yz had three children. Returned to work as a salesclerk 15 years ago to improve family finances. Children all married. Four years ago, her husband died suddenly of a heart attack, leaving little savings. MN has moved to a small apartment to be near daughter, I. I’s husband, Jo, has an alcohol problem. MN’s apartment is now a haven for I and her two children, Ke, age 6 years, and Lu, age 3 years. MN feels responsible for helping them; she feels tense and nervous but denies feeling depressed. She has friends, but rarely discusses family problems: “I’d rather keep them to myself. I don’t like gossip.” During the assessment, she reports being raised as a Catholic, but that she stopped attending church after the death of her husband. Although she states her faith is still important to her, she now describes having no faith community or spiritual support system. She feels this has contributed to her sense of anxiety. She is typically up at 7:00 AM, works 9:00 AM to 5:30 PM, and eats dinner alone.

95. Personal & social Hx … documents Exercise and diet: Gets little exercise. Diet high in carbohydrates. Safety measures: Uses seat belt regularly. Uses sunblock. Medications kept in an unlocked medicine cabinet. Cleaning solutions in unlocked cabinet below sink. Tobacco : About 1 pack of cigarettes per day since age 18 (36 pack-years). Alcohol/drugs : Wine on rare occasions. No illicit drugs. Sexual history: Little interest in sex, and not sexually active. Her deceased husband was her only sexual partner. No history of sexually transmitted infection. No concerns about HIV infection

96. Review of Systems- functional inquiry Is often challenging for beginning students. Asking series of questions going from “head to toe.” Prepare the patient for the questions, by saying- “The next part of the history may feel like a million questions, but they are important and I want to be thorough.” Start with a fairly general question-e.g. “How are your ears and hearing?” “How about your lungs and breathing?” “Any trouble with your heart?” “How is your digestion?” “How about your bowels?”

97. Review of Systems- functional inquiry.. each regional system, ask: “Have you ever had any . . .?” General- Usual weight, recent weight change, Weakness, fatigue, fever. Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles

98. Functional inquiry… Head, Eyes, Ears, Nose, Throat (HEENT)- Head : Headache, head injury, dizziness, lightheadedness. Eyes : Vision, glasses or contact lenses, pain, redness, excessive tearing, double vision, blurred vision , flashing lights, glaucoma, cataracts. Ears : Hearing, tinnitus, vertigo, earaches, discharge. If hearing is decreased, use or nonuse of hearing aids. Nose and sinuses : Frequent colds, nasal stuffiness , discharge, or itching, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums, dentures, if any, and how they fit , sore tongue, dry mouth, frequent sore throats, hoarseness.

99. Functional inquiry… Neck Lumps, “swollen glands,” goiter, pain, or stiffness in the neck. Breasts: Lumps, pain, or discomfort, nipple discharge. Respiratory Cough, sputum (color, quantity; presence of blood or hemoptysis ), shortness of breath ( dyspnea ), wheezing, pain with a deep breath ( pleuritic pain ) Cardiovascular chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing ( orthopnea ); need to sit up at night to ease breathing ( paroxysmal nocturnal dyspnea ); swelling in the hands, ankles, or feet ( edema ).

100. Functional inquiry… Gastrointestinal- Trouble swallowing, heartburn(epigastric pain), appetite, nausea, vomiting, color and size of stools, change in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis. Peripheral Vascular Intermittent leg pain with exertion ( claudication ); leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness.

101. Functional inquiry… Urinary: Frequency of urination, polyuria, nighttime urination ( nocturia ), urgency, burning or pain during urination, blood in the urine ( hematuria ), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. Musculoskeletal- Muscle or joint pains, stiffness, arthritis, gout, and backache. If present, describe location of affected joints or muscles, presence of any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (for example, morning or evening), duration, and any history of trauma.

102. Male Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual interest ( libido ), function, satisfaction. Female: Age at menarche; Menstrual regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. A ge at menopause, Menopausal symptoms, postmenopausal bleeding. Vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments. Sexual interest, satisfaction, any problems, including pain during intercourse( dyspareunia ). Functional inquiry…Genital

103. Functional inquiry… Psychiatric: Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. Neurologic Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness or loss of sensation, tingling or “ pins and needles ,” tremors or other involuntary movements, seizures. Hematologic: Anemia, easy bruising or bleeding. Endocrine Heat or cold intolerance, excessive sweating, excessive thirst ( polydipsia ), hunger ( polyphagia ), or urine output ( polyuria ).

104. Review of Systems documentations General: Has gained 10 kg in the past 4 years. Skin: No rashes or other changes. Head, Eyes, Ears, Nose, Throat (HEENT): See Present Illness. Head: No history of head injury. Eyes: Reading glasses for 5 years, last checked 1 year ago. No symptoms. Ears: Hearing good. No tinnitus, vertigo, infections. Nose, sinuses: No hay fever, sinus trouble. Throat (or mouth and pharynx): No tooth pain or gum bleeding. Neck: No lumps, goiter, pain. No swollen glands. Breasts: No lumps, pain, discharge. Respiratory: No cough, wheezing, shortness of breath. Cardiovascular: No dyspnea, orthopnea, chest pain, palpitations.

105. Review of Systems documentations Gastrointestinal: Appetite good; no nausea, vomiting, indigestion. Bowel movement about once daily, though sometimes has hard stools for 2 to 3 days when especially tense; no diarrhea or bleeding. No pain, jaundice, gallbladder or liver problems. clinically Urinary: No frequency, dysuria, hematuria, or recent flank pain; occasionally loses urine when coughing. Genital: No vaginal or pelvic infections. No dyspareunia. Peripheral vascular: No history of phlebitis or leg pain. Musculoskeletal: Mild low backaches, often at the end of the workday; no radiation into the legs; used to do back exercises, but not now. No other joint pain. Psychiatric: No history of depression or treatment for psychiatric disorders. Neurologic: No fainting, seizures, motor or sensory loss. No memory problems. Hematologic: No easy bleeding or bruising. Endocrine: No known heat or cold intolerance. No polyuria, polydipsia

106. References Lynn S. Bickley, Peter G. Szilagyi, Richard M. Hoffman. Bates’ guide to physical examination and history taking.13 th edition. Philadelphia: Wolters Kluwer;2021 Carolyn Jarvis, Ann Eckhardt. Physical Examination & Health Assessment. 8 th edition. St. Louis, Missouri: Elsevier Inc;2020