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

Objectives At the end of this unit students will be able to: Organize patient’s health history Determine the sequence of physical examination Identify techniques of examination for each component of the physical examination

Patient Assessment: Comprehensive or Focused?

Determining the Scope of Your Assessment Questions to ask yourself: What is the patient’s problem? What is their chief complaint? Is it severe? Consideration must be given to: Clinical setting Time available

Comprehensive Assessment Includes all the elements of the health history Complete physical examination Is appropriate for new patients in the office or hospital Provides fundamental and personalized knowledge about the patient Strengthens the clinician – patient relationship

Comprehensive Assessment Helps identify or rule out physical causes related to patient concerns Provides baselines for future assessments Creates platform for health promotion through education and counseling Develops proficiency in the essential skills of physical examination

Focused Assessment or Problem Oriented Assessment Is appropriate for established patients, especially during routine or urgent care visits Addresses focused concerns or symptoms Assesses symptoms restricted to a specific body system Applies examination methods relevant to assessing the concern or problem as precisely and carefully as possible

Subjective Data What the patient tells you The history, from Chief Complaint through Review of Systems

Objective Data What you detect through observation and obtaining medical history All physical examination findings

Comprehensive Assessment of the Adult

Health History Contains 7 components: Identifying Data and Source of the History Chief Complaint Present Illness Past History Family History Personal and Social History Review of Systems

Identifying Data Identifying Data – demographics, ie. age, gender, occupation, etc. Source of History – usually the patient, but can be a family member or friend, letter of referral, or the medical record Note: Reliability of information varies according to patient’s memory, trust, reason for visit, and mood

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

Chief Complaint The patient’s reason for coming to the clinical setting today. One or more symptoms or concerns that caused the patient to seek medical care

Chief Complaint: Quote the Source of Information! When possible quote the patient in their own word. This means this should be written in quotation marks. If the patient is not the one you are obtaining information from quote them.

History of Present Illness; Amplifies the Chief Complaint; describes how each symptom developed Includes patient’s thoughts and feelings about the illness Answers the question: What led the up to the patient’s current state of health? Chronologic account of progress of patients symptoms

History of Present Illness Narrative should include: The onset of the problem The setting in which it has developed Manifestations Treatments attempted Answers question: Did anything make it better or worse?

History of Present Illness Each principle symptom should be well-characterized, with descriptions of: Location Quality Quantity or Severity Timing, including onset, duration, and frequency Setting in which it occurs Factors that have aggravated or relieved the symptoms Associated manifestations

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

History of Present Illness Allergies (food, drugs, and environmental factors) including specific reactions to each identified. Smoking, include substance and type. Note: Cigarette use normally measured in ppd or pack per day. Alcohol and drug use should always be investigated. Note amount, how often, and for how long.

Past Medical History List childhood illnesses List adult illnesses and surgeries with dates Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety Hospitalizations Psychiatric illnesses and time frame, diagnoses, hospitalizations, and treatment

Immunizations - Find out whether the patient has received vaccines for: Tetanus Pertussis Diphtheria Polio Measles Rubella, Mumps Hepatitis A Hepatitis B Pneumococci Meningitis Human Papilloma Virus Varicella Influenza

Screening Tests Tuberculin skin tests Pap smears Mammograms Stool tests for occult blood Cholesterol tests Sickle cell tests HIV tests Hepatitis A, B, C

Family History Outlines or diagrams age and health, or age and cause of death of siblings, parents, and grandparents Documents presence or absence of specific illnesses in family

Diseases/Conditions to evaluate include the following: Coronary artery disease Hypertension Cerebrovascular Accident (Stroke) Diabetes Cancer Tuberculosis Asthma Mental Illness Allergies Suicide Alcoholism Kidney Disease Lung Disease Hyperlipidemia Arthritis Headaches Seizure disorder Substance abuse Liver disease

Personal and Social History Describes educational level, family of origin, current household, personal interests, and lifestyle Captures the patient’s personality and interests, sources of support, coping style, strengths, and fears Includes occupation and the last year of schooling; home situation, and significant others; sources of stress, both recent and long term; important life experiences,

Personal and Social History Conveys lifestyle habits that promote health or create risk Use of safety measures Alternative health practices

Review of Systems Documents presence or absence of common symptoms related to each major body system Think about asking a series of questions going from head-to-toe Start with fairly general questions about systems that may be of concern based on Chief Complaint and History of Present Illness.

Review of Systems Make note, that you will vary the need for additional questions depending on the patient’s age, complaints, and general state of health and your clinical judgment. Review of systems questions may uncover problems that the patient has overlooked, or may not be aware are concerning.

General Weight Weakness Fatigue Fever

Skin Rashes Lumps Sores Itching Dryness Changes in color Changes in hair or nails Changes in color or size of moles

Head Headache Head injury Dizziness Syncope Vertigo Lumps Sores

Eyes Vision Glasses or contacts lenses; last examination Spots Pain Redness Excessive tearing Double or blurred vision Spots Specks Flashing lights Glaucoma Cataracts Itching Decreased tearing

Ears Hearing Tinnitus Vertigo Earaches Infection Discharge Use of hearing assistive devices

Nose and Sinuses Frequent colds Nasal stuffiness Discharge Itching Hay fever Nosebleeds Sinus Infections

Throat (Mouth and Pharynx) Condition of teeth and gums Bleeding gums Dentures Last dental examination Sore tongue Dry mouth Frequent sore throats Hoarseness

Neck Swollen glands Goiter Lumps Pain Stiffness

Breast Lumps Pain Nipple discharge Self-Examination practices

Respiratory Cough Sputum (color, quantity) Hemoptysis Dyspnea Wheezing Pleurisy Chest X-Ray

Cardiovascular Heart conditions Hypertension Rheumatic fever Heart murmurs Chest pain Palpitations Dypnea Orthopnea Paroxysmal nocturnal dyspnea Orthopnea Paroxysmal nocturnal dyspnea Edema Electrocardiograms Echocardiograms Past other cardiovascular tests

Gastrointestinal Pain with defecation Trouble swallowing Rectal bleeding or black tarry stools Hemorrhoids Constipation Diarrhea Abdominal pain Food intolerance Excessive belching or flatulence Liver or gallbladder problems Trouble swallowing Heartburn Decreased/Increased appetite Nausea/vomiting Jaundice Hepatitis Bowel movements Stool color, size, and consistency Change in bowel habits

Peripheral Vascular Intermittent claudication Leg cramps Varicose veins Deep vein thrombosis Swelling in calves, legs, or feet Color change in fingertips or toes during cold weather Swelling with redness or tenderness

Urinary Frequency of urination Polyuria Nocturia Urgency Burning or pain during urination Hematuria Urinary infections Kidney or flank pain Kidney stones Ureteral colic Suprapubic pain Incontinence Reduced urinary stream Hesitancy Dribbling

Genital: Male Hernias Discharge from or sores on the penis Testicular pain or masses Scrotal pain or swelling History of sexually transmitted diseases and their treatments Sexual habit, interest, function, satisfaction, birth control methods, condom use and problems Concern about HIV infection or exposure

Genital: Female Age of onset of menarche, regularity, frequency, and duration of menstrual cycle; amount of bleeding; bleeding between cycles or after intercourse; last menstrual period; dysmenorrhea; premenstrual syndrome Age at menopause, menopausal symptoms, post menopausal bleeding If the patient was born before 1971, exposure to Diethylstilbestrol (DES) from maternal use during pregnancy because it has been linked to cervical cancer

Genital: Female Vaginal discharge, itching, sores, lumps, sexually transmitted diseases and treatments Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth control methods Sexual preference, interests, function, satisfaction, any problems, including dyspareunia Concerns about HIV infection or exposure

Musculoskeletal Muscle or joint pain Stiffness Arthritis Gout Backache If present, describe location or affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms duration, and any history of trauma Neck or low back pain Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, or weakness

Psychiatric Nervousness Tension Mood Including depression Memory change Suicide attempts

Neurologic Changes in mood, attention, or speech Changes in orientation, memory, insight, or judgment Headache Dizziness Vertigo Syncope Blackouts Seizures Weakness Paralysis Numbness or loss of sensation Tingling or “pins and needles” Tremors or involuntary seizures

Hematologic Anemia Easy bruising or bleeding Past transfusions Transfusion reactions

Endocrine Thyroid conditions Heat or cold intolerance Excessive sweating Excessive thirst or hunger Polyuria Change in glove or shoe size

Beginning the Evaluation: Setting the Stage

Preparing for the Physical Examination Reflect on your approach to the patient Adjust the lightening and the environment Make the patient comfortable Check your equipment Choose the sequence of examination

Reflect on Your Approach to the Patient Be straightforward Identify yourself Appear calm, organized, and competent, even if you feel differently Reassure the patient – when evaluating the area involved in the chief complaint, assure the patient that you may spend additional time assessing this area, but it is not necessarily because you find anything abnormal

Reflect on Your Approach to the Patient DON’T WASTE TIME!!! Be systematic in your assessment of the patient while ensuring that appropriate draping is maintained Examine each region of the body, and at the same time think of the patient as a whole, noting discomfort, or anxiety Communicate with the patient, and let them know what you are going to do BEFORE doing it.

Adjust the Lightening and the Environment SAVE YOUR BACK!!! Adjust the bed waist high BE SURE TO LOWER IT AFTER ASSESSMENT IS COMPLETED! Ask the patient if you may lower the television or radio volume if the sound is interfering with your assessment When performing the assessment make sure good overhead lightening is utilized

Equipment for the Physical Examination Ophthalmoscope Otoscope Flashlight or penlight Tongue depressors Flexible tape measure, preferably marked in centimeters Thermometer Watch with a second hand Sphygmomanometer Stethoscope

Equipment for the Physical Examination Gloves Reflex hammer Tuning forks Q-tips, safety pins, cotton swabs Small notebook Black pen, #2 pencil

CHECK YOUR EQUIPMENT PRIOR TO ENTERING THE PATIENT’S ROOM CHECK YOUR EQUIPMENT PRIOR TO ENTERING THE PATIENT’S ROOM. MAKE SURE YOU HAVE EVERYTHING YOU NEED TO COMPLETE YOUR ASSESSMENT PRIOR TO ENTERING THE PATIENT’S ROOM.

Make the Patient Comfortable Showing concern for privacy and patient modesty must become ingrained in your professional behavior Be sure to close nearby doors and draw curtains in the hospital or examination room PRIOR to beginning physical examination Your goal is to visualize one area of the body at a time

Make the Patient Comfortable Prepare the patient for the examination by briefly describing what you are going to do PRIOR to starting the evaluation and removing the drapes As you proceed with the examination, continue to be conscious of the patient’s comfort level, and keep them informed about what you are doing, or about to do. Make sure that your instructions to the patient at each step in the examination are clear, and courteous.

Make the Patient Comfortable Be sensitive to the patient’s feelings and physical comfort When you have completed the examination, show your attentiveness, by rearranging the patients pillows, or adding blankets for warmth; make sure their immediate environment is to their satisfaction Be sure to lower the bed completely, and make sure side rails are up and call bell is in the patient’s reach As you leave be sure to WASH YOUR HANDS!

Choose the Sequence of the Examination: Work from Head-to-Toe! General Survey Vital Signs Skin Head Neurological System Cardiovascular Respiratory Breast and Axillae Abdomen Peripheral Vascular Musculoskeletal Optional: Women-Pelvic and Rectal Examination Optional: Men – Prostate and Rectal Examination

Cardinal Techniques of Examination Inspection Palpation Percussion Auscultation

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

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

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

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

Standard and MRSA Precautions Based on the principle that ALL blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents Apply to all patients in any setting Hand hygiene Use of gloves, gowns, and mouth, nose and eye protection Respiratory hygiene and cough etiquette Patient isolation criteria Precautions relating to equipment, toys, and solid surfaces, and handling of laundry; Safe needle injection practices

Universal Precautions Set of guidelines designed to prevent transmission of HIV, hepatitis B and C, and other bloodborne pathogens when providing first aid or health care. The following fluids are considered potentially infectious: All blood and other body fluids containing visible blood Semen Vaginal secretions Cerebrospinal fluid Synovial, pleural, peritoneal, pericardial, and amniotic fluids

Protective Barriers Gloves Gowns Aprons Masks Protective eyewear Hats Shoe covers

Positioning for the Examination Be conscious of how often you ask the patient to change positions during the physical examination Utilize your examination sequence with the goal of minimizing how often you ask the patient to change position.

Medical Terminology

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

Terms Comprehensive Assessment Family History Focused Assessment Subjective Data Objective Data Identifying Data Chief Compliant History of Present Illness Past Medical History Family History Personal and Social History Review of Systems Ophthalmoscope Otoscope Tongue Depressor Thermometer Sphygmomanometer Stethoscope

Terms Inspection Palpation Percussion Auscultation Standard Precautions Universal Precautions Methicillin-resistant staphylococus aureus

Medical Abbreviations

S – Subjective O – Objective CC – Chief Compliant HPI – History of present illness PMH – Past medical history ROS – Review of systems ETOH – Alcohol PPD – tuberculin skin test ppd – packs per day (cigarette smoking)

HIV – Human immunodeficiency virus HBV – Hepatitis B virus ADLs – Activities of dialy living HEENT – Head, Eyes, Ears, Nose, Throat CDC – Centers for Disease Control and Prevention MRSA – Methicillin – resistant Staphylococcus aureus

VIP of the Week

Ibn al-Haytham Instructions: Research this person and write the following in your interactive notebook. Who is he? What significance does he have to medicine or science? How can I utilize his contribution in my profession? How does his contribution affect the world?

Questions