Physical Examination and History Taking: Comprehensive Assessment of the Adult Practicum of Health Science Technology 2009 - 2010

Physical Physical Examination and Examination and History Taking: History Taking: Comprehensive Comprehensive

Assessment of the Assessment of the AdultAdult

Practicum of Health Practicum of Health Science Technology Science Technology

2009 - 20102009 - 2010

ObjectivesObjectives

At the end of this unit students At the end of this unit students will be able to:will be able to:

Organize patient’s health historyOrganize patient’s health history Determine the sequence of Determine the sequence of

physical examinationphysical examination Identify techniques of Identify techniques of

examination for each component examination for each component of the physical examinationof the physical examination

Patient Assessment: Patient Assessment: Comprehensive or Comprehensive or

Focused?Focused?

Determining the Scope of Determining the Scope of Your AssessmentYour Assessment

Questions to ask yourself:Questions to ask yourself: What is the patient’s problem? What is the patient’s problem?

What is their chief complaint?What is their chief complaint? Is it severe?Is it severe?

Consideration must be given to:Consideration must be given to: Clinical settingClinical setting Time availableTime available

Comprehensive Comprehensive AssessmentAssessment

Includes all the elements of Includes all the elements of the health historythe health history

Complete physical examinationComplete physical examination Is appropriate for new patients Is appropriate for new patients

in the office or hospitalin the office or hospital Provides fundamental and Provides fundamental and

personalized knowledge about personalized knowledge about the patientthe patient

Strengthens the clinician – Strengthens the clinician – patient relationshippatient relationship

Comprehensive Comprehensive AssessmentAssessment

Helps identify or rule out Helps identify or rule out physical causes related to physical causes related to patient concernspatient concerns

Provides baselines for future Provides baselines for future assessmentsassessments

Creates platform for health Creates platform for health promotion through education promotion through education and counselingand counseling

Develops proficiency in the Develops proficiency in the essential skills of physical essential skills of physical examinationexamination

Focused Assessment or Focused Assessment or Problem Oriented Problem Oriented

AssessmentAssessment Is appropriate for established Is appropriate for established

patients, especially during patients, especially during routine or urgent care visitsroutine or urgent care visits

Addresses focused concerns or Addresses focused concerns or symptomssymptoms

Assesses symptoms restricted to Assesses symptoms restricted to a specific body systema specific body system

Applies examination methods Applies examination methods relevant to assessing the concern relevant to assessing the concern or problem as precisely and or problem as precisely and carefully as possiblecarefully as possible

Subjective DataSubjective Data

What the What the patient tells youpatient tells you

The history, The history, from Chief from Chief Complaint Complaint through Review through Review of Systemsof Systems

Objective DataObjective Data

What you What you detect through detect through observation and observation and obtaining obtaining medical historymedical history

All physical All physical examination examination findingsfindings

Comprehensive Assessment Comprehensive Assessment of the Adultof the Adult

Health HistoryHealth History

Contains 7 components:Contains 7 components:

1.1. Identifying Data and Source of Identifying Data and Source of the Historythe History

2.2. Chief ComplaintChief Complaint

3.3. Present IllnessPresent Illness

4.4. Past HistoryPast History

5.5. Family HistoryFamily History

6.6. Personal and Social HistoryPersonal and Social History

7.7. Review of SystemsReview of Systems

Identifying DataIdentifying Data

Identifying Data – demographics, ie. Identifying Data – demographics, ie. age, gender, occupation, etc.age, gender, occupation, etc.

Source of History – usually the Source of History – usually the patient, but can be a family member patient, but can be a family member or friend, letter of referral, or the or friend, letter of referral, or the medical recordmedical record

Note: Reliability of information varies Note: Reliability of information varies according to patient’s memory, trust, according to patient’s memory, trust, reason for visit, and moodreason for visit, and mood

Date and Time Date and Time Everything!!!Everything!!!

Be sure to document the date Be sure to document the date and time that you evaluate the and time that you evaluate the patient, especially in urgent, patient, especially in urgent, emergent, or hospital settings.emergent, or hospital settings.

Chief ComplaintChief Complaint

The patient’s reason for coming The patient’s reason for coming to the clinical setting today.to the clinical setting today.

One or more symptoms or One or more symptoms or concerns that caused the patient concerns that caused the patient to seek medical careto seek medical care

Chief Complaint: Quote the Chief Complaint: Quote the Source of Information!Source of Information!

When possible quote the patient in When possible quote the patient in their own word. This means this their own word. This means this should be written in quotation should be written in quotation marks.marks.

If the patient is not the one you are If the patient is not the one you are obtaining information from quote obtaining information from quote them.them.

History of Present History of Present Illness;Illness;

Amplifies the Chief Complaint; Amplifies the Chief Complaint; describes how each symptom describes how each symptom developeddeveloped

Includes patient’s thoughts and Includes patient’s thoughts and feelings about the illnessfeelings about the illness

Answers the question: What led Answers the question: What led the up to the patient’s current the up to the patient’s current state of health?state of health?

Chronologic account of progress Chronologic account of progress of patients symptomsof patients symptoms

History of Present IllnessHistory of Present Illness

Narrative should include:Narrative should include: The onset of the problemThe onset of the problem The setting in which it has The setting in which it has

developeddeveloped ManifestationsManifestations Treatments attemptedTreatments attempted Answers question: Did anything Answers question: Did anything

make it better or worse?make it better or worse?


Each principle symptom should be well-Each principle symptom should be well-characterized, with descriptions of:characterized, with descriptions of:

1.1. LocationLocation2.2. QualityQuality3.3. Quantity or SeverityQuantity or Severity4.4. Timing, including onset, duration, Timing, including onset, duration,

and frequencyand frequency5.5. Setting in which it occursSetting in which it occurs6.6. Factors that have aggravated or Factors that have aggravated or

relieved the symptomsrelieved the symptoms7.7. Associated manifestationsAssociated manifestations


Medications should be noted, Medications should be noted, including name, dose, route, and including name, dose, route, and frequency of use. Be sure to frequency of use. Be sure to include home remedies and include home remedies and alternative medicine practices, non-alternative medicine practices, non-prescriptive drugs, vitamins, prescriptive drugs, vitamins, minerals, herbal supplements, minerals, herbal supplements, contraceptives (women), and contraceptives (women), and medicines borrowed from family medicines borrowed from family members or friends.members or friends.

History of Present IllnessHistory of Present Illness Allergies (food, drugs, and Allergies (food, drugs, and

environmental factors) including environmental factors) including specific reactions to each identified.specific reactions to each identified.

Smoking, include substance and Smoking, include substance and type. Note: Cigarette use normally type. Note: Cigarette use normally measured in ppd or pack per day.measured in ppd or pack per day.

Alcohol and drug use should always Alcohol and drug use should always be investigated. Note amount, how be investigated. Note amount, how often, and for how long.often, and for how long.

Past Medical HistoryPast Medical History

List childhood illnessesList childhood illnesses List adult illnesses and surgeries with List adult illnesses and surgeries with

datesdates Includes health maintenance practices Includes health maintenance practices

such as immunizations, screening such as immunizations, screening tests, lifestyle issues, and home safetytests, lifestyle issues, and home safety

HospitalizationsHospitalizations Psychiatric illnesses and time frame, Psychiatric illnesses and time frame,

diagnoses, hospitalizations, and diagnoses, hospitalizations, and treatmenttreatment

Immunizations - Find out whether Immunizations - Find out whether the patient has received vaccines the patient has received vaccines for:for:

TetanusTetanus PertussisPertussis DiphtheriaDiphtheria PolioPolio MeaslesMeasles Rubella,Rubella, MumpsMumps

Hepatitis AHepatitis A Hepatitis BHepatitis B PneumococciPneumococci MeningitisMeningitis Human Human

Papilloma VirusPapilloma Virus VaricellaVaricella InfluenzaInfluenza

Screening TestsScreening Tests

Tuberculin skin testsTuberculin skin tests Pap smearsPap smears MammogramsMammograms Stool tests for occult bloodStool tests for occult blood Cholesterol testsCholesterol tests Sickle cell testsSickle cell tests HIV testsHIV tests Hepatitis A, B, CHepatitis A, B, C

Family HistoryFamily History

Outlines or diagrams age and Outlines or diagrams age and health, or age and cause of death health, or age and cause of death of siblings, parents, and of siblings, parents, and grandparentsgrandparents

Documents presence or absence Documents presence or absence of specific illnesses in familyof specific illnesses in family

Diseases/Conditions to Diseases/Conditions to evaluate include the evaluate include the following:following: Coronary artery Coronary artery

diseasedisease HypertensionHypertension Cerebrovascular Cerebrovascular

Accident (Stroke)Accident (Stroke) DiabetesDiabetes CancerCancer TuberculosisTuberculosis AsthmaAsthma Mental IllnessMental Illness AllergiesAllergies

SuicideSuicide AlcoholismAlcoholism Kidney DiseaseKidney Disease Lung DiseaseLung Disease HyperlipidemiaHyperlipidemia ArthritisArthritis HeadachesHeadaches Seizure disorderSeizure disorder Substance abuseSubstance abuse Liver diseaseLiver disease

Personal and Social Personal and Social HistoryHistory

Describes educational level, Describes educational level, family of origin, current family of origin, current household, personal interests, household, personal interests, and lifestyleand lifestyle

Captures the patient’s personality Captures the patient’s personality and interests, sources of support, and interests, sources of support, coping style, strengths, and fearscoping style, strengths, and fears

Includes occupation and the last Includes occupation and the last year of schooling; home situation, year of schooling; home situation, and significant others; sources of and significant others; sources of stress, both recent and long term; stress, both recent and long term; important life experiences, important life experiences,

Personal and Social Personal and Social HistoryHistory

Conveys lifestyle habits that Conveys lifestyle habits that promote health or create riskpromote health or create risk

Use of safety measuresUse of safety measures Alternative health practicesAlternative health practices

Review of SystemsReview of Systems

Documents presence or absence Documents presence or absence of common symptoms related to of common symptoms related to each major body systemeach major body system

Think about asking a series of Think about asking a series of questions going from head-to-toequestions going from head-to-toe

Start with fairly general Start with fairly general questions about systems that questions about systems that may be of concern based on Chief may be of concern based on Chief Complaint and History of Present Complaint and History of Present Illness.Illness.

Review of SystemsReview of Systems

Make note, that you will vary Make note, that you will vary the need for additional the need for additional questions depending on the questions depending on the patient’s age, complaints, and patient’s age, complaints, and general state of health and general state of health and your clinical judgment.your clinical judgment.

Review of systems questions Review of systems questions may uncover problems that the may uncover problems that the patient has overlooked, or may patient has overlooked, or may not be aware are concerning.not be aware are concerning.

GeneralGeneral

WeightWeight WeaknessWeakness FatigueFatigue FeverFever

SkinSkin

RashesRashes LumpsLumps SoresSores ItchingItching DrynessDryness Changes in colorChanges in color Changes in hair or nailsChanges in hair or nails Changes in color or size of molesChanges in color or size of moles

HeadHead

HeadacheHeadache Head injuryHead injury DizzinessDizziness SyncopeSyncope VertigoVertigo LumpsLumps SoresSores

EyesEyes

VisionVision Glasses or Glasses or

contacts lenses; contacts lenses; last examinationlast examination

PainPain RednessRedness Excessive tearingExcessive tearing Double or Double or

blurred visionblurred vision

SpotsSpots SpecksSpecks Flashing lightsFlashing lights GlaucomaGlaucoma CataractsCataracts ItchingItching Decreased tearingDecreased tearing

EarsEars

HearingHearing TinnitusTinnitus VertigoVertigo EarachesEaraches InfectionInfection DischargeDischarge Use of hearing assistive devicesUse of hearing assistive devices

Nose and SinusesNose and Sinuses

Frequent coldsFrequent colds Nasal stuffinessNasal stuffiness DischargeDischarge ItchingItching Hay feverHay fever NosebleedsNosebleeds Sinus InfectionsSinus Infections

Throat (Mouth and Throat (Mouth and Pharynx)Pharynx)

Condition of teeth and gumsCondition of teeth and gums Bleeding gumsBleeding gums DenturesDentures Last dental examinationLast dental examination Sore tongueSore tongue Dry mouthDry mouth Frequent sore throatsFrequent sore throats HoarsenessHoarseness

NeckNeck

Swollen glandsSwollen glands GoiterGoiter LumpsLumps PainPain StiffnessStiffness

BreastBreast

LumpsLumps PainPain Nipple dischargeNipple discharge Self-Examination practicesSelf-Examination practices

RespiratoryRespiratory

CoughCough Sputum (color, quantity)Sputum (color, quantity) HemoptysisHemoptysis DyspneaDyspnea Wheezing Wheezing PleurisyPleurisy Chest X-RayChest X-Ray

CardiovascCardiovascularular

Heart conditionsHeart conditions HypertensionHypertension Rheumatic feverRheumatic fever Heart murmursHeart murmurs Chest painChest pain PalpitationsPalpitations DypneaDypnea OrthopneaOrthopnea Paroxysmal Paroxysmal

nocturnal nocturnal dyspneadyspnea

OrthopneaOrthopnea Paroxysmal Paroxysmal

nocturnal dyspneanocturnal dyspnea EdemaEdema ElectrocardiogramElectrocardiogram

ss EchocardiogramsEchocardiograms Past other Past other

cardiovascular cardiovascular teststests

GastrointestGastrointestinalinal

Trouble swallowingTrouble swallowing HeartburnHeartburn Decreased/Increased Decreased/Increased

appetiteappetite Nausea/vomitingNausea/vomiting JaundiceJaundice HepatitisHepatitis Bowel movementsBowel movements Stool color, size, and Stool color, size, and

consistencyconsistency Change in bowel Change in bowel

habitshabits

Pain with defecationPain with defecation Rectal bleeding or Rectal bleeding or

black tarry stoolsblack tarry stools HemorrhoidsHemorrhoids ConstipationConstipation DiarrheaDiarrhea Abdominal painAbdominal pain Food intoleranceFood intolerance Excessive belching or Excessive belching or

flatulenceflatulence Liver or gallbladder Liver or gallbladder

problemsproblems

Peripheral VascularPeripheral Vascular

Intermittent claudicationIntermittent claudication Leg crampsLeg cramps Varicose veinsVaricose veins Deep vein thrombosisDeep vein thrombosis Swelling in calves, legs, or feetSwelling in calves, legs, or feet Color change in fingertips or toes Color change in fingertips or toes

during cold weatherduring cold weather Swelling with redness or Swelling with redness or

tendernesstenderness

UrinaryUrinary

Frequency of Frequency of urinationurination

PolyuriaPolyuria NocturiaNocturia UrgencyUrgency Burning or pain Burning or pain

during urinationduring urination HematuriaHematuria Urinary infectionsUrinary infections

Kidney or flank Kidney or flank painpain

Kidney stonesKidney stones Ureteral colicUreteral colic Suprapubic painSuprapubic pain IncontinenceIncontinence Reduced urinary Reduced urinary

streamstream Hesitancy Hesitancy DribblingDribbling

Genital: MaleGenital: Male HerniasHernias Discharge from or sores on the penisDischarge from or sores on the penis Testicular pain or massesTesticular pain or masses Scrotal pain or swellingScrotal pain or swelling History of sexually transmitted diseases History of sexually transmitted diseases

and their treatmentsand their treatments Sexual habit, interest, function, Sexual habit, interest, function,

satisfaction, birth control methods, satisfaction, birth control methods, condom use and problemscondom use and problems

Concern about HIV infection or Concern about HIV infection or exposureexposure

Genital: FemaleGenital: Female Age of onset of menarche, regularity, Age of onset of menarche, regularity,

frequency, and duration of menstrual frequency, and duration of menstrual cycle; amount of bleeding; bleeding cycle; amount of bleeding; bleeding between cycles or after intercourse; last between cycles or after intercourse; last menstrual period; dysmenorrhea; menstrual period; dysmenorrhea; premenstrual syndromepremenstrual syndrome

Age at menopause, menopausal Age at menopause, menopausal symptoms, post menopausal bleedingsymptoms, post menopausal bleeding

If the patient was born before 1971, If the patient was born before 1971, exposure to Diethylstilbestrol (DES) from exposure to Diethylstilbestrol (DES) from maternal use during pregnancy because maternal use during pregnancy because it has been linked to cervical cancerit has been linked to cervical cancer

Genital: FemaleGenital: Female Vaginal discharge, itching, sores, lumps, Vaginal discharge, itching, sores, lumps,

sexually transmitted diseases and sexually transmitted diseases and treatmentstreatments

Number of pregnancies, number and type Number of pregnancies, number and type of deliveries, number of abortions of deliveries, number of abortions (spontaneous and induced), (spontaneous and induced), complications of pregnancy, birth control complications of pregnancy, birth control methodsmethods

Sexual preference, interests, function, Sexual preference, interests, function, satisfaction, any problems, including satisfaction, any problems, including dyspareuniadyspareunia

Concerns about HIV infection or exposureConcerns about HIV infection or exposure

MusculoskeletalMusculoskeletal Muscle or joint painMuscle or joint pain StiffnessStiffness ArthritisArthritis GoutGout BackacheBackache If present, describe location or affected joints If present, describe location or affected joints

or muscles, any swelling, redness, pain, or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation tenderness, stiffness, weakness, or limitation of motion or activity; include timing of of motion or activity; include timing of symptoms duration, and any history of traumasymptoms duration, and any history of trauma

Neck or low back painNeck or low back pain Joint pain with systemic features such as fever, Joint pain with systemic features such as fever,

chills, rash, anorexia, weight loss, or weaknesschills, rash, anorexia, weight loss, or weakness

PsychiatricPsychiatric

NervousnessNervousness TensionTension MoodMood Including depressionIncluding depression Memory changeMemory change Suicide attempts Suicide attempts

NeurologicNeurologic Changes in mood, Changes in mood,

attention, or attention, or speechspeech

Changes in Changes in orientation, orientation, memory, insight, or memory, insight, or judgmentjudgment

HeadacheHeadache DizzinessDizziness VertigoVertigo SyncopeSyncope BlackoutsBlackouts

SeizuresSeizures WeaknessWeakness ParalysisParalysis Numbness or Numbness or

loss of sensationloss of sensation Tingling or “pins Tingling or “pins

and needles”and needles” Tremors or Tremors or

involuntary involuntary seizuresseizures

HematologicHematologic

AnemiaAnemia Easy bruising or bleedingEasy bruising or bleeding Past transfusionsPast transfusions Transfusion reactionsTransfusion reactions

EndocrineEndocrine

Thyroid conditionsThyroid conditions Heat or cold intoleranceHeat or cold intolerance Excessive sweatingExcessive sweating Excessive thirst or hungerExcessive thirst or hunger PolyuriaPolyuria Change in glove or shoe sizeChange in glove or shoe size

Beginning the Evaluation: Beginning the Evaluation: Setting the StageSetting the Stage

Preparing for the Physical Preparing for the Physical ExaminationExamination

Reflect on your approach to the Reflect on your approach to the patientpatient

Adjust the lightening and the Adjust the lightening and the environmentenvironment

Make the patient comfortableMake the patient comfortable Check your equipmentCheck your equipment Choose the sequence of Choose the sequence of

examinationexamination

Reflect on Your Approach to Reflect on Your Approach to the Patientthe Patient

Be straightforwardBe straightforward Identify yourselfIdentify yourself Appear calm, organized, and Appear calm, organized, and

competent, even if you feel differentlycompetent, even if you feel differently Reassure the patient – when evaluating Reassure the patient – when evaluating

the area involved in the chief the area involved in the chief complaint, assure the patient that you complaint, assure the patient that you may spend additional time assessing may spend additional time assessing this area, but it is not necessarily this area, but it is not necessarily because you find anything abnormalbecause you find anything abnormal

Reflect on Your Approach to Reflect on Your Approach to the Patientthe Patient

DON’T WASTE TIME!!!DON’T WASTE TIME!!! Be systematic in your assessment of Be systematic in your assessment of

the patient while ensuring that the patient while ensuring that appropriate draping is maintainedappropriate draping is maintained

Examine each region of the body, and Examine each region of the body, and at the same time think of the patient as at the same time think of the patient as a whole, noting discomfort, or anxietya whole, noting discomfort, or anxiety

Communicate with the patient, and let Communicate with the patient, and let them know what you are going to do them know what you are going to do BEFORE doing it. BEFORE doing it.

Adjust the Lightening and Adjust the Lightening and the Environmentthe Environment

SAVE YOUR BACK!!!SAVE YOUR BACK!!! Adjust the bed waist highAdjust the bed waist high

BE SURE TO LOWER IT AFTER BE SURE TO LOWER IT AFTER ASSESSMENT IS COMPLETED!ASSESSMENT IS COMPLETED!

Ask the patient if you may lower the Ask the patient if you may lower the television or radio volume if the sound television or radio volume if the sound is interfering with your assessmentis interfering with your assessment

When performing the assessment When performing the assessment make sure good overhead lightening is make sure good overhead lightening is utilizedutilized

Equipment for the PhysicalEquipment for the Physical ExaminationExamination

OphthalmoscopeOphthalmoscope OtoscopeOtoscope Flashlight or penlightFlashlight or penlight Tongue depressorsTongue depressors Flexible tape measure, preferably Flexible tape measure, preferably

marked in centimetersmarked in centimeters ThermometerThermometer Watch with a second handWatch with a second hand SphygmomanometerSphygmomanometer StethoscopeStethoscope

Equipment for the Physical Equipment for the Physical ExaminationExamination

GlovesGloves Reflex hammerReflex hammer Tuning forksTuning forks Q-tips, safety pins, cotton swabsQ-tips, safety pins, cotton swabs Small notebookSmall notebook Black pen, #2 pencilBlack pen, #2 pencil

CHECK YOUR CHECK YOUR EQUIPMENT EQUIPMENT PRIORPRIOR TO TO

ENTERING THE ENTERING THE PATIENT’S ROOM. PATIENT’S ROOM.

MAKE SURE YOU HAVE MAKE SURE YOU HAVE EVERYTHING YOU NEED EVERYTHING YOU NEED

TO COMPLETE YOUR TO COMPLETE YOUR ASSESSMENT ASSESSMENT PRIORPRIOR TO TO

ENTERING THE ENTERING THE PATIENT’S ROOM.PATIENT’S ROOM.

Make the Patient Make the Patient ComfortableComfortable

Showing concern for privacy and Showing concern for privacy and patient modesty must become patient modesty must become ingrained in your professional ingrained in your professional behaviorbehavior

Be sure to close nearby doors Be sure to close nearby doors and draw curtains in the hospital and draw curtains in the hospital or examination room or examination room PRIORPRIOR to to beginning physical examinationbeginning physical examination

Your goal is to visualize one area Your goal is to visualize one area of the body at a timeof the body at a time


Prepare the patient for the examination Prepare the patient for the examination by briefly describing what you are going by briefly describing what you are going to do to do PRIORPRIOR to starting the evaluation to starting the evaluation and removing the drapesand removing the drapes

As you proceed with the examination, As you proceed with the examination, continue to be conscious of the patient’s continue to be conscious of the patient’s comfort level, and keep them informed comfort level, and keep them informed about what you are doing, or about to about what you are doing, or about to do.do.

Make sure that your instructions to the Make sure that your instructions to the patient at each step in the examination patient at each step in the examination are clear, and courteous.are clear, and courteous.


Be sensitive to the patient’s feelings Be sensitive to the patient’s feelings and physical comfortand physical comfort

When you have completed the When you have completed the examination, show your attentiveness, examination, show your attentiveness, by rearranging the patients pillows, or by rearranging the patients pillows, or adding blankets for warmth; make sure adding blankets for warmth; make sure their immediate environment is to their their immediate environment is to their satisfactionsatisfaction

Be sure to lower the bed completely, Be sure to lower the bed completely, and make sure side rails are up and and make sure side rails are up and call bell is in the patient’s reachcall bell is in the patient’s reach

As you leave be sure to As you leave be sure to WASH YOUR WASH YOUR HANDSHANDS!!

Choose the Sequence of the Choose the Sequence of the Examination: Work from Head-to-Examination: Work from Head-to-Toe!Toe!

1.1. General SurveyGeneral Survey2.2. Vital SignsVital Signs3.3. SkinSkin4.4. HeadHead5.5. Neurological Neurological

SystemSystem6.6. CardiovascularCardiovascular7.7. RespiratoryRespiratory8.8. Breast and Breast and

AxillaeAxillae

9.9. AbdomenAbdomen10.10. Peripheral Peripheral

VascularVascular11.11. MusculoskeletalMusculoskeletal12.12. Optional: Women-Optional: Women-

Pelvic and Rectal Pelvic and Rectal ExaminationExamination

13.13. Optional: Men – Optional: Men – Prostate and Prostate and Rectal Rectal ExaminationExamination

Cardinal Techniques of Cardinal Techniques of ExaminationExamination

InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation

InspectionInspection

Close observation of the details Close observation of the details of the patient’s appearance, of the patient’s appearance, behavior, and movement.behavior, and movement.

PalpationPalpation

Tactile pressure from the palmar Tactile pressure from the palmar fingers or fingerpads to assess fingers or fingerpads to assess areas of skin elevation, areas of skin elevation, depression, warmth, or depression, warmth, or tenderness; lymph nodes; pulses; tenderness; lymph nodes; pulses; contours and sizes of organs and contours and sizes of organs and masses; and crepitus in the masses; and crepitus in the joints.joints.

PercussionPercussion

Use of the striking or plexor finger, Use of the striking or plexor finger, usually the third, to deliver a rapid usually the third, to deliver a rapid tap or blow against the distal tap or blow against the distal pleximeter finger, usually the third pleximeter finger, usually the third finger of the left hand laid against finger of the left hand laid against a surface of the chest or abdomen, a surface of the chest or abdomen, to evoke a sound wave such as to evoke a sound wave such as resonance or dullness from the resonance or dullness from the underlying tissue or organs.underlying tissue or organs.

AuscultationAuscultation

Use of the diaphragm and bell of Use of the diaphragm and bell of the stethoscope to detect the the stethoscope to detect the characteristics of heart, lung, characteristics of heart, lung, and bowel sounds, including and bowel sounds, including location, timing, duration, pitch, location, timing, duration, pitch, and intensityand intensity

Standard and MRSA Standard and MRSA PrecautionsPrecautions

Based on the principle that ALL blood, body Based on the principle that ALL blood, body fluids, secretions, excretions except sweat, fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may nonintact skin, and mucous membranes may contain transmissible infectious agentscontain transmissible infectious agents

Apply to all patients in any settingApply to all patients in any setting Hand hygieneHand hygiene Use of gloves, gowns, and mouth, nose and Use of gloves, gowns, and mouth, nose and

eye protectioneye protection Respiratory hygiene and cough etiquetteRespiratory hygiene and cough etiquette Patient isolation criteriaPatient isolation criteria Precautions relating to equipment, toys, and Precautions relating to equipment, toys, and

solid surfaces, and handling of laundry;solid surfaces, and handling of laundry; Safe needle injection practicesSafe needle injection practices

Universal PrecautionsUniversal Precautions

Set of guidelines designed to prevent Set of guidelines designed to prevent transmission of HIV, hepatitis B and transmission of HIV, hepatitis B and C, and other bloodborne pathogens C, and other bloodborne pathogens when providing first aid or health when providing first aid or health care. The following fluids are care. The following fluids are considered potentially infectious: considered potentially infectious:

All blood and other body fluids All blood and other body fluids containing visible bloodcontaining visible blood

SemenSemen Vaginal secretionsVaginal secretions Cerebrospinal fluidCerebrospinal fluid Synovial, pleural, peritoneal, Synovial, pleural, peritoneal,

pericardial, and amniotic fluidspericardial, and amniotic fluids

Protective BarriersProtective Barriers

GlovesGloves GownsGowns ApronsAprons MasksMasks Protective eyewearProtective eyewear HatsHats Shoe coversShoe covers

Positioning for the Positioning for the ExaminationExamination

Be conscious of how often you Be conscious of how often you ask the patient to change ask the patient to change positions during the physical positions during the physical examinationexamination

Utilize your examination Utilize your examination sequence with the goal of sequence with the goal of minimizing how often you ask minimizing how often you ask the patient to change position.the patient to change position.

Medical TerminologyMedical Terminology

InstructionsInstructions

Define the following terms in your Define the following terms in your interactive note book. Utilize interactive note book. Utilize KIM technique with the K = Key KIM technique with the K = Key word/ key term; I = Information/ word/ key term; I = Information/ Definition; and M = Memory Cue Definition; and M = Memory Cue – something that will help you to – something that will help you to remember the term. Maybe a remember the term. Maybe a picture, word, or phrase.picture, word, or phrase.

TermsTerms Comprehensive Comprehensive

AssessmentAssessment Focused Focused

AssessmentAssessment Subjective DataSubjective Data Objective DataObjective Data Identifying DataIdentifying Data Chief CompliantChief Compliant History of Present History of Present

IllnessIllness Past Medical Past Medical

HistoryHistory

Family HistoryFamily History Personal and Personal and

Social HistorySocial History Review of SystemsReview of Systems OphthalmoscopeOphthalmoscope OtoscopeOtoscope Tongue DepressorTongue Depressor ThermometerThermometer SphygmomanometSphygmomanomet

erer StethoscopeStethoscope

TermsTerms

InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation Standard PrecautionsStandard Precautions Universal PrecautionsUniversal Precautions Methicillin-resistant Methicillin-resistant

staphylococus aureus staphylococus aureus

Medical AbbreviationsMedical Abbreviations

S – SubjectiveS – Subjective O – ObjectiveO – Objective CC – Chief CompliantCC – Chief Compliant HPI – History of present illnessHPI – History of present illness PMH – Past medical historyPMH – Past medical history ROS – Review of systemsROS – Review of systems ETOH – AlcoholETOH – Alcohol PPD – tuberculin skin testPPD – tuberculin skin test ppd – packs per day (cigarette ppd – packs per day (cigarette

smoking)smoking)

HIV – Human immunodeficiency virusHIV – Human immunodeficiency virus HBV – Hepatitis B virusHBV – Hepatitis B virus ADLs – Activities of dialy livingADLs – Activities of dialy living HEENT – Head, Eyes, Ears, Nose, HEENT – Head, Eyes, Ears, Nose,

ThroatThroat CDC – Centers for Disease Control CDC – Centers for Disease Control

and Preventionand Prevention MRSA – Methicillin – resistant MRSA – Methicillin – resistant

Staphylococcus aureusStaphylococcus aureus

VIP of the WeekVIP of the Week

Ibn al-HaythamIbn al-Haytham

Instructions: Research this person and Instructions: Research this person and write the following in your interactive write the following in your interactive notebook.notebook.

Who is he?Who is he? What significance does he have to What significance does he have to

medicine or science?medicine or science? How can I utilize his contribution in How can I utilize his contribution in

my profession?my profession? How does his contribution affect the How does his contribution affect the

world?world?

QuestionsQuestions