Health Assessment_Intergrative holistic assessment.pptx

health

1. HEALTH ASSESSMENT An introduction By Linda Grace

2. Learning Objectives Define health assessment Describe the purpose, types, importance of health assessment Describe and practice the steps involved in taking a nursing health history Discuss the process of interviewing a client.

3. D efinitions Health: Health assessment; Refers to a systematic, deliberative and interactive process by which a nurse uses critical thinking skills to collect, validate, analyze and synthesize data so as to make a judgment about the health status and life processes of individuals, families and communities. Data is both subjective (health history) and objective (physical examination) Physical assessment (objective data); Involves collection of objective data on the client’s physical health status.

4. The Nursing process Assessment is step one of the nursing process.

5. Health assessment cont’d Focuses on both curative and preventive health care. Preventive health care; 3 categories, primary, secondary and tertiary prevention. Each level of prevention is based on a thorough assessment of the client's health as status. Periodic health assessment needed to be performed by a physician, or a nurse

6. Objectives of health assessment Surveillance of health status I dentification of occult disease, For screening , and follow-up care Increasing client participation in health care Accurately define the health and risk care needs for individuals

7. Objectives of health assessment cont’d Overall the major objective of health assessment is to; To make a judgement (nursing diagnosis, collaborative care and referral) on the patients actual or potential health problems

8. Important to note In order to achieve the objectives of health assessment, it should be; The periodic assessment, at regular intervals Health assessment is shared with the client in a clear and understandable manner The client must share in decision making for his own care.

9. Frequency of routine comprehensive assessment The persons under (35) years every (4 – 5) years The persons from (35 – 45) every (2 – 3) years. Persons from (45-55) years of age undergo a thorough health assessment every year. Persons over (55) years may needs assessment every 6 months or less Every time a client presents with a health care need.

10. 1. Provides a systematic and continuous collection of client data 2. It focuses on client responses to health problems 3. The nurse carefully examines the client ’ s body parts to determine any abnormalities 4. The nurse relies on data from different sources which can indicate significant clinical problems 5. Health assessment provides a base line used to plan the clients care Importance of nursing health assessment

11. Importance of health assessment 6. Health assessment helps the nurse to diagnose client ’ s problem & the intervention 7. Complete health assessment involves a more detailed review of client’s condition 8. Health assessment influence the choice of therapies & client's responses

12. Purposes of health assessment 1. Gather data 2. Confirm or refuse data obtained in the health history 3. To identify nursing diagnoses/medical dx 4. To make clinical judgments about client's changing health status 5.To evaluate bio-psycho-social and spiritual outcomes of care

13. Approaches to health assessment Health Orientation Approach Performed in relation to the present health status of the patient, the daily activities necessary to maintain health and the internal and external environmental resources that are available to promote and improve health. This approach is appropriate when patient comes for a routine check up but is inadequate when patient is ill. Disease or Problem Oriented Approach Information gathered relates to the present disease condition and how it compares with the patient’s previous health status, the patient’s experience (symptoms) of the illness . What this means and what coping mechanisms are being used. Here patient’s experiences and illness process are demonstrated

14. Types of Assessment Comprehensive assessment : is usually the initial assessment it very thorough and includes detailed health history and physical examination and examine the client's overall health and functional health status .

15. Types of Assessment Initial assessment: assessment performed within a specified time on admission. E.g. nursing admission assessment Problem-focused assessment: used to determine status of a specific problem identified in an earlier assessment. e.g . problem on urination-assessment on fluid intake and urine output hourly. Maybe an initial or ongoing assessment.

16. Types of assessment Emergency assessment: rapid assessment done during any physiologic crisis of the client to identify life threatening problems. .g . assessment of a client’s airway, breathing status & circulation after a cardiac arrest. Time-lapsed (periodic) assessment: reassessment of client’s functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.

17. Types of data Mainly 2 types of data are obtained during a health assessment of a client Subjective data Objective data

18. Subjective data Data given by a client or family, next of kin These are symptoms or sensations reported Such information can only be elicited and verified only by the client Examples may include symptoms (pain, hunger) Feeling e.g happiness, sadness Perceptions, desires, preferences, beliefs, ideas, values.

19. Subjective data continued Biographical information (name, age, religion, occupation History of present concern All health history Data from review of systems Health and lifestyle practices

20. Objective data Data directly observed by the nurse Includes Physical characteristics Body functions (heart or respiratory rate) Appearance e.g dress and hygiene Behavior, mood and affect Measurement, blood pressure, temperature, height Laboratory and imaging results

21. Components of a comprehensive health Assessment Health History Subjective data Symptoms and health history Obtained through interview/review of systems Identifies actual or potential health problems, support system, teaching needs, discharge and referral needs U se of effective communications skills is requisite Physical Assessment Objective data Obtained by observation and physical assessment techniques (all physical examination findings or signs) Laboratory information and test data Completes client’s health picture/validates subjective (health history). Documentation of all client data

22. Steps for health Assessement Collection of subjective data Collection of objective data Validation of data Documentation of data These steps may overlap

23. Validation of data Crucial step Occurs along with the collection of subjective and objective data Ensures that all relevant assessment data is collected and is accurate Methods of validation include; Rechecking data Clarifying with the client by asking additional questions Verify with another health care professional Compare your objective finding with the subjective information

24. Documenting data “Not documented = Not done” A very important step Forms the database for the entire nursing process and provides data to the entire healthcare team Important in making valid conclusions and promotes effective communication. Should be accurate and systematic Usually guided by institutional policy and guidelines.

25. Modals for documentation Computer-based documentation systems (Health/patient information databases)..[Electronic health/Medical records (HER, EMR) Paper based documentation All assessment data should be accurately validated and documented to minimize medical errors and improve patient safety

26. 1. The Interview Definition: Communication process that focuses on the client's development of psychological, physiological, socio-cultural, and spiritual responses, that can be treated with nursing & collaborative interventions

27. Fig. 1 REMEMBER : The communication process .

28. Major purpose of a health interview: To obtain health history and to elicit symptoms and the time course of their development. The interview is conducted before physical examination is done. Components of nursing interview 1. Introductory phase 2. Working phase 3. Termination phase

29. 1. Introductory phase: Introduction of yourself and explaining the purpose of the interview to the client. Before asking questions, Let client to feel Comfort, Privacy and Confidentiality

30. Working phase: The nurse must listen and observe cues in addition to using critical thinking skills to validate information received from the client. The nurse identify client's problems and goals. Termination phase: 1.The nurse summarizes information obtained during the working phase 2. Validates problems and goals with the client. 3.Making plans to resolve the problems (nursing diagnosis and collaborative problems are identified and discussed with the client)

31. Communications techniques during interview Interactional Skills Listening Attending Paraphrasing Leading Questioning Reflecting Summarizing

32. Communications techniques during interview Listening: - Paying Undivided Attention to What the Client Says and Does Attending: - Giving Full Attention to Verbal and Nonverbal Messages

33. Communication techniques c’td Paraphrasing: - Restating the Client’s Basic Message Leading : - Used to Encourage Open Communication Techniques Direct leading Focusing Questioning

34. Communication techniques c’td Questioning: - Direct Way of Speaking with Clients to Obtain Subjective Data for Decision Making and Planning Care Closed and open-ended questions Reflecting: - Repeating the Client’s Verbal or Nonverbal Message for the Client’s Benefit to Show that the Nurse Has Empathy with the Client’s Thoughts, Feelings, or Experiences Summarizing:- The Process of Gathering the Ideas, Feelings, and Themes That Clients Have Discussed Throughout the Interview and Restating Them in Several General Statements

35. Communications techniques: Questioning 1. Types of questions : Begin with open ended questions to assess client's feelings e.g. what, how, which “ Use closed ended question to obtain facts e.g." when, did…etc Use list to obtain specific answers e.g. "is pain sever, dull sharp Explore all data that deviate from normal e.g. “increase or decrease the problem

36. 2. Types of statements to be use: Repeat your perception of client's response to clarify information and encourage verbalization 3. Accept the client silence to recognize thoughts 4. Avoid some communication styles e.g. Excessive or not enough eye contact. Doing other things during getting history. Biased or leading questions e.g. "you don't feel bad“ why not ask, “how does that make you feel” Relying on memory to recall information

37. BEWARE: Communication barriers Barriers to Effective Client Interactions False reassurance Interrupting or changing the subject Passing judgment Cross-examination Using technical terms Encountering sensitive issues Age, cultural, regional and emotional variations

38. 5. Specific age variations :- Pediatric clients: validate information from parents. Geriatric clients: use simple words and assess hearing acuity 6. Emotional variations: Be calm with angry clients and those who are anxious and express interest with depressed client Sensitive issues "e.g. sexuality, dying, spirituality" you must be aware of your own thought regarding these things (self awareness very crucial).

39. 7. Cultural variations: Be aware of possible cultural variations in the communication styles of self and clients: Factors: ethnicity, body language, customs, nationality etc 8. Use culture broker: Use culture broker as middleman if your client not speak your language. Use pictures for non reading clients.

40. Other barriers cont’d Diversity and Impact on the Nurse - Client Interactions Education Health status Level of intelligence

41. Chapter (2) Psychosocial assessment

42. Psychosocial assessment Psychological assessment involves person's psychological growth and development throughout his life. Discuss crises with the clients to assess relationship between health & illness. “ It depends on multiple G&D theories e.g. Erickson, Piaget, and Freud …. etc.

43. Stages of Age Infancy period: birth to 12 months Neonatal Stage: birth-28 days Infancy Stage: 1-12 months Early childhood Stage: It’s refers to two integrated stages of development Toddler: 1 - 3years. Preschool: 3 - 6 years. Middle childhood 6-12 years Late childhood: Pre pubertal: 10 – 13 years. Adolescence: 13 - 19 years Young adulthood 20-35 years Middle adulthood 40-60years Late adulthood 60 and more

44. Chapter (3) Nutritional assessment

45. Nutritional assessment Nutrition plays a major role in the way an individual looks, feels,& behaves. The body ability to fight disease greatly depends on the individual's nutritional status

46. Major goals of nutritional assessment 1. Identification of malnutrition. 2. Identification of over consumption 3. Identification of optimal nutritional status. Components of Nutritional Assessment 1. Anthropometric measurement. 2. Biochemical measurement. 3. Clinical examination. 4. Dietary analysis

47. 1. Anthropometric measurement Measurement of size, weight, and proportions of human body. Measurement includes: height, weight, skin fold thickness, and circumference of various body parts, including the head, chest, and arm. Assess body mass index (BMI) to shows a direct and continuous relationship to morbidity and mortality in studies of large populations . High ratios of waist to hip circumference are associated with higher risk for illness & decreased life span. BMI = (Wt. in kilograms ) = 60 = 60 = 23.4 (High in meters) 2 (1.6)2 2.56

48. BMI RANGE Condition Rang kg/m 2 Very thin less than 16.0 Thin 16.0 - 18.4 Average/normal 18.5- 24.9 Overweight 25–29.9 Obese 30-34.9 Highly obese ≥ 35

49. 2. Biochemical Measurement Useful in indicating malnutrition or the development of diseases as a result of over consumption of nutrients. Serum and urine are commonly used for biochemical assessment. In assessment of malnutrition, commonly tests include : total lymphocyte count, albumin, serum transferrin, hemoglobin, and hematocrit …etc. These values taken with anthropometric measurements, give a good overall picture of an individual's skeletal and visceral protein status as well as fat reserves and immunologic response.

50. 3. Clinical examination Involves, close physical evaluation and may reveal signs suggesting malnutrition or over consumption of nutrients. Although examination alone doesn't permit definitive diagnosis of nutritional problem, it should not be overlooked in nutritional assessment

51. Nutritional assessment technique for clinical examination A. Types of information needed Diet: Describe the type: regular or not, special, "e.g. teeth problem, sensitive mouth. Usual mealtimes: How many meals a day: when? Which are heavy meals? Appetite: "Good, fair, poor, too good “ polyphagia ". Weight: stable? How has it changed?

52. Food preferences: e.g." prefers beef to other meats" Food dislike: What & Why? Culture related? Usual eating places: Home, snack shops, restaurants. Ability to eat: describe inabilities, dental problems: "ill fitting dentures, difficulties with chewing or swallowing Elimination " urine & stool: nature, frequency problems Exercise & physical activity : how extensive or deficient

53. Psycho social - cultural factors: Review any thing which can affect on proper nutrition Taking Medications which affect the eating habits Laboratory determinations e.g.: “Hemoglobin, protein, albumin, cholesterol, urinalyses" Height, weight, body type "small, medium, large" After obtaining information, summarize your findings and determine the nutritional diagnosis and nutritional plan of care . Imbalanced nutrition: Less than body requirements, related to lack of knowledge and inadequate food intake Risk for infection, related to protein-calorie malnutrition

54. B. Signs & symptoms of malnutrition Dry and thin hair Yellowish lump around eye, white rings around both eyes, and pale conjunctiva Redness and swelling of lips especially corners of mouth Teeth caries & abnormal missing of it Dryness of skin (xerosis): sandpaper feels of skin Spoon shaped Nails " Koilonychia “ anemia Tachycardia, elevated blood pressure due to excessive sodium intake and excessive cholesterol, fat, or caloric intake Muscle weakness and growth retardation

55. 4. Dietary analysis Food represent cultural and ethnic background and socio- economic status and have many emotional and psychological meaning Assessment includes usual foods consumed & habits of food The nurse ask the client to recall every thing consumed within the past 24 hour including all foods, fluid, vitamins, minerals or other supplements to identify the optimal meals Should not bias the client's response to question based on the interviewer's personal habits or knowledge of recommended food consumption

56. Diseases affected by nutritional problems 1- Obesity: excess of body fat. 2- Diabetes mellitus. 3- Hypertension. 4- Coronary heart disease. 5- Cancer.

57. Chapter (4) Sleep-wakefulness patterns

58. Assessment of sleep-wakefulness patterns Normal human has “ homeostasis ” (ability to maintain a relative internal constancy) Any person may complain of sleep-pattern disturbance as a primary problem or secondary due to another condition 1/4 of clients who seek health care complain of a difficulty related to sleep

59. Factors affecting length and quality of sleep 1. Anxiety related to the need for meeting a tasks, such as waking at an early hour for work. 2. The promise of pleasurable activity such as starting a vacation. 3. The conditioned patterns of sleeping. 4. Physiologic wake up. 5. Age differences. 6. Physiologic alteration, such as diseases

60. NOTE: Good sleep depends on the number of awakenings and the total number of sleeping hours The nurse can assess sleep pattern by doing interview with the client or using special charts or by EEG Disorders related to sleep 1.Sleep disturbances affects family life, employment, and general social adjustment 2. Feelings of fatigue, irritability and difficulty in concentrating 3. Difficulty in maintaining orientation

61. 4. Illusions, hallucination (visual & tactile ) 5. Decreased psychomotor ability with decreased incentive to work 7. Tremor of hands Increase in gluco -corticoid and adrenergic hormone secretion 9. Increase anxiety with sense of tiredness 10. Insomnia "short end sleeping periods“ 11. Sleep apnea "periodic cessation of breathing that occurs during sleep

62. 12. Hypersomnia: "sleeping for excessive periods” the sleep period may be extended to 16-18 hours a day 13. Peri-hypersomnia. "Condition that is described as an increased use for sleep "18-20 hours a day" lasts for only few days 14. Narcolepsy "excessive day time drowsiness or uncontrolled onset of sleep. 15. Cataplexy: abrupt weakness or paralysis of voluntary muscles e.g. arms, legs & face last from half second to 10 minutes, once or twice a year 16. Hypnagogic hallucinations: " Disturbing or frightening dream that occur as client is falling a sleep

63. Assessment of sleep habits Let the client record the times of going to sleep and awakening periods, including naps. Allow client to described their sleep habits in their own words You can ask the following questions: How have you been sleeping?‖ Can you tell me about your sleeping habits?" Are you getting enough rest?" Tell me about your sleep problem" A Good comprehensive History includes: a general sleep history AND psychological history

64. Frameworks for collecting client data 2 frameworks that are peculiar to Nursing Generic Nursing History format Gordon’s functional health pattern assessment model

65. Generic Nursing History Framework Provides a foundation for identifying client problems Provides a focus for physical examination. Mainly focus on collecting subjective data. Major components Biographical data Reasons for seeking health care History of presenting health concern Past health histories Family histories Review of systems for current health problems Lifestyle and health practices (Activities of daily living) Developmental levels Photocopy page 19 in Weber & Kelley, 2014

66. Gordon’s functional heath pattern assessment model Useful in collecting patient data to formulate nursing diagnosis. Consists of 11 functional health patterns A pattern is a sequence of related behavior that assists a nurse in collecting and categorizing data Can be applied to clients of all ages, families and communities

67. The functional health pattern framework summary Client profile Developmental history Health-perception- health management pattern Nutritional metabolic pattern Elimination pattern Activity-exercise pattern Sexuality-reproduction pattern Sleep-rest pattern Sensory-perceptual pattern Cognitive pattern Role-relationship pattern Self-perception-self-concept pattern Coping-stress tolerance pattern Value-belief pattern

68. Chapter (5) THE Health History taking

69. Definition of Health History Systematic collection of subjective data stated by the client , on there health condition Data is used to determine a client’s functional health pattern/status. A Health History Interview is a Planned, Formal Interaction Between the Nurse and the Client

70. Phases of taking health history Two phases:- The interview phase which elicits the information (primary sources) The recording phase (secondary source). Phases : B Preinteraction phase Initial interview Focused interview

71. Guidelines for Taking Nursing History Private, comfortable, and quiet environment. Allow the client to state problems and expectations for the interview. Orient the client the structure , purposes , and expectations of the history.

72. Guidelines for Taking Nursing History cont.. Communicate and negotiate priorities with the client Listen more than talk. Observe non verbal communications e.g. "body language, voice tone, and appearance".

73. Guidelines for Taking Nursing History cont.. Review information about past health history before starting interview. Balance between allowing a client to talk in an unstructured manner and the need to structure requested information. Clarify the client's definitions (terms & descriptors)

74. Guidelines for Taking Nursing History cont.. Avoid yes or no question (when detailed information is desired). Write adequate notes for recording? Record nursing health history soon after interview.

75. Types of Nursing Health History Complete health history : taken on initial visits to health care facilities. Interval health history : collect information in visits following the initial data base is collected. Problem- focused health history : collect data about a specific problem

76. Health History: components Bio- dermographic data D-Date N-Name A-Age S-Sex R-Region T-Tribe A-Address N-Next of kinLevel of education Occupation Others: Distance to the nearest health centre Source of referral Past health history Presenting complaint History of present complaint Past medical history Past surgical history Past obstetric history Past gynaecology history Family history Social history Activities of daily living. Review of systems.

77. Purpose of obtaining Biographic data Date: Record keeping Name: For identification Age: For Dose calculation, ward allocation: children from adults, disease distribution Sex: Disease distribution, ward allocation Religion: To observe religious beliefs

78. Purpose of obtaining biographic data.. Tribe: To observe cultural beliefs Address: For easy patient follow up Next of Kin: someone from whom consent can be obtained from in case patient is a minor or unconscience .

79. Purpose of obtaining biographic data.... Level of education: Helps to know how much information to give someone during health education and in the simplest terms. Occupation: To rule out occupation hazards Distance to the nearest health centre: to know the health seeking behaviour of some one.

80. Health/medical history: order Presenting complaint History of present complaint Past medical history Past surgical history Past obstetric history Past gynaecology history Family history Social history Activities of daily living. Review of systems.

81. Presenting complaint Signs and symptoms Duration of the presenting signs and symptoms This in usually the main reason for seeking healthcare. .......................many times it will be pain

82. 2- Chief Complaint: “Reason For Hospitalization Examples of chief complaints: Chest pain for 3 days. Swollen ankles for 2 weeks. Fever and headache for 24 hours. Pap smear needed. Physical examination needed for camp.

83. 3-History of present illness Gathering information relevant to the chief complaint, and the client's problem, including essential and relevant data, and self medical treatment .

84. Component of Present Illness Introduction: "client's summary and usual health". Investigation of symptoms: "onset, date, gradual or sudden, duration, frequency, location, quality, and alleviating or aggravating factors". Negative information. Relevant family information. Disability "affected the client's total life".

85. SYMPTOM ANALYSIS P Q R S T a. Provocative or Palliative First occurrence : What were you doing when you first experienced or noticed the symptom? What to trigger it ? stress? Position?, activity? What seems to cause it or make it worse? For a psychological symptom . What relieves the symptom : change diet? Change position ? Take medication ? Being active? Aggravation: what makes the symptom worse?

86. SYMPTOM ANALYSIS P Q R S T b. Quality Or Quantity QUALITY : How would you describe the symptom- how it feels, looks, or sounds? QUANTITY: How much are you experiencing now? Is it so much that it prevents you from performing any activity?

87. SYMPTOM ANALYSIS P Q R S T C. Region Or Radiation Region : Where does the symptom occur? Radiation : Does it travel down your back or arm, up your neck or down your legs?

88. SYMPTOM ANALYSIS P Q R S T d. Severity scale Severity How bad is symptom at its worst? Course Does the symptom seem to be getting better, getting worse?

89. SYMPTOM ANALYSIS P Q R S T e. Timing Onset : On what date did the symptom first occur Type of onset : How did the symptom start sudden? Gradually? Frequency : How often do you experience the symptom ; hourly ? Daily ? Weekly? monthly Duration : How long does an episode of the symptom last

90. Past medical history (PMH) Ask about: patient’s general condition currently, in the near past and in general Previous admission (index or not) Any current medical conditions. Previous or current infectious conditions e.g ,malaria, RTI, rheumatic fever, Hep B etc Past medical illness esp chronic conditions: rheumatic fever, DM, heart diseases, hypertension, renal disease, CVA (stroke), COPD, epilepsy, asthma, SCD etc

91. PMHx cont’d Past drug history Are you on or have been on any drug/drugs? Type and reason name, dose/day, route, how long Side effects Any drug allergies and symptoms

92. Past surgical history ( PSHx ) Ask about: Any previous surgical operations, time done and recovery. History of blood transfusion and tolerance to BT. H/o accidents, trauma/injury and fractures. Any surgical conditions

93. P Obstetrics & Gynecological history _women only Ask about: Menarche/menopause Previous pregnancies and deliveries, LNMP, EDD Menses, duration, flow Any gynecological conditions and complications Any family planning method ever used and when. ETC

94. Family history Ask about: Family in general, family members Familial conditions e.g sickle cell disease,DM , hypertension, cancers, and genetic conditions A family tree can help summarize these assessments

95. Family history, sample family tree with DM as a condition Pt X DM DM DM

96. Social history Ask about: Social habits: Smoking : When started, how long been smoking, when stopped or contemplating smoking, If currently smoking. How many cigarettes. Smoking is assessed in packs/year:- number of year smoking*packs/day. Some qns : Do you smoke? Have you ever smoked for a significant period of time? When did you stop? How much do you/did you smoke on average every day?

97. Social history continued Social habits: Alcohol . Do you drink alcohol How much alcohol do you drink in an average week? (express in units) Occupation: What do you do for a living? Travel: Have you travelled anywhere recently? Housing: What sort of housing do you live in? Do you live with anyone else at home? Determine if they live alone in a house, flat, sheltered housing, residential or nursing home: Source of water and neighborhood. Recreation : Any activities for recreation. Do you have any pets?

98. Activities of daily living How has the illness affected your ability to perform your ADL. How are you coping at home? Are you able to cook/clean/wash/go shopping on your own or do you need help? Do you need help to move around? Do you need a walking stick/wheelchair? Do you have stairs to climb? Do you have any carers? How often do they come?

99. Review of systems (ROS) Collection of data about the past and the present of each of the client physical and physiological systems. (Review of the client’s physical, sociologic, and psychological health status may identify hidden problems and provides an opportunity to indicate client strength and disabilities

100. ROS components: systematic approach. General review of skin, hair, head, face, eyes, ears, nose, sinuses, mouth, throat, neck nodes and breasts. Assessment of respiratory and cardiovascular system. Assessment of gastrointestinal system. Assessment of urinary system. Assessment of genital system. Assessment of extremities and musculoskeletal system. Assessment of endocrine system. Assessment of heamatologic system

101. Ros , general health & HEENT General health: Ask about: height, weight (recent weight gain or loss) and general wellbeing Neuropsychological : h/o convulsions, fatigue, weakness, depression. Chlidren ; ask abt h/o convulsions Head: h/o head trauma, headache, dizziness(vertigo), or memory loss. Children: shape of the head, fontanelles , trauma Hair: h/o; changes in texture, color, distribution or loss. Children: also ask abt ; scalp lesions or itchness

102. Skin; rashes, changes in moles or other lesions and skin color e.g in vitiligo Children also birthmarks, ecchymotic marks

103. Eyes: h/o vision disturbances, use of glasses or contact lenses, eye disease (glaucoma, cataracts, short/long sightedness, infection), date of last vision examination. Children: also h/o ability to follow a moving object, difficulty in vision, eye infections Ears: ask about h/o: hearing difficulties, use of hearing aids, ear disease(infection, discharge, dizziness), hearing test exam.

104. Nose : h/o epistasis , infections, discharge ( rhinorrhea ), loss of smell, sinus problems h/o of nose surgery e.g in polyps.. Mouth: dental carries or cavities, use of dentures, braces or retainers, inflammations and lesions in the oral cavity, loss of taste, date of last dental visit. Children; number of teeth present, cavities, false teeth and extraction. Throat : h/o difficult swallowing, infections e.g tonsilitis or hoarseness Children; history of streptococcal infection.

105. Neck: h/o of neck stiffness, swollen LN, neck trauma. Chest: discharge or masses in the breasts (male/female), BSE in females, Chest trauma. Children; symmetry of the chest

106. Respiratory system: H/O; cough (productive or non-productive), dyspnea, chest pain, stridor , wheezing, shortness of breath, asthma, previous RS conditions. Children: frequent colds or cough, previous severe respiratory illness Cardiovascular system, CVS: Ask abt chest pain ( e.g left sides radiating to the shoullder , angina pectoris pain), h/o of hypertension, edema of extremities, past heart disease, fatigue and activity tolerance, palpitations. h/o of anemias , children also: cyanosis, shortness of breath, tolerance to play.

107. Gastrointestinal system: ask about Appetite, nausea, vomiting, diarrhoea , jaundice constipation, hemorrhoids, bowel habits, color of stools, previous GI surgery. Genito -urinary system, ask about; Urinary frequency, urgency, incontinence or hestitancy . Pain on urination, blood in urine, color of urine. Amount of urine. Female: vaginal discharge, pruritis , infections, STIs, Males: prostate problems, STIs, sexual difficulties e.g erectile dysfuntion or premature ejaculation.

108. Musculoskeletal and extremities: h/o trauma, joint pain, swelling and stiffness. Bone pain, fractures, varicose veins. Back; pain, stiffness, h/o spinal injury

109. Hematological system: anemia, transfusions ( reason for, any reactions to transfusion and severity); bleeding tendencies, easy bruising, patechiae ( bleeding under the skin). Endocrine system: thyroid disease, DM, any hormone replacement therapy.