NUR 378: Health Assessment Across the Lifespan
HISTORY & PHYSICAL EXAMINATION CHEATSHEET
Objectives: To review, organize & evaluate the importance of patient data To maintain a specific order of the annual exam To specifically describe positive and negative findings in writing To be familiar with the purpose of the annual exam To document the annual exam with objectivity and clarity To review pertinent facts of documentation and the format for a patient history
Review of the Rules of Documentation Maintain an order of documentation Inspection, palpation, … Make the headings clear, use indentations and spacing to accentuate the organization Use medical terminology, unless quoting the patient Arrange the HPI in chronological order Keep physical exam findings & diagnosis OUT OF THE HISTORY Do not try to list ALL the negative findings but concentrate on the most important and as it pertains to the complaint
Review of the Rules of Documentation Avoid redundancy Chart the description of your findings DO NOT USE OPINION WORDS: WNL, intact, abnormal, etc. Be objective, avoid hostility, disapproval or moralizing comments Basic identifying data starts the history, while a paragraph form of the general survey starts the PE NEVER CHANGE A RECORD, USE WHITE OUT, PENCIL OR ERASE!!!!!! Cross out with a line date and initial
The Annual Exam By definition, this is a form of preventive medicine consisting of physical and diagnostic evaluations guided not by what has been deemed cost effective in any given population It is driven by an individual’s unique risks and balanced by available resources to effectively detect preventable illnesses.
Chief Complaint “I am here for my yearly exam” “I am here for a well-checkup” “I am here for a well-women exam” The second part of the CC contains the duration: “It has been 2 years since my last checkup” “I am here for a checkup. My last one was over 3 years ago.”
NUR 378: Health Assessment Across the Lifespan
History of the Present Illness This part of the documentation is has a different content from those that have a complaint. If the patient presents for an annual physical with a stated complaint as well, the HPI would contain two parts: One, exploring the past year, past exam and results, and current risks and screenings An HPI developed on the complaint “I’m here for a physical but I found a lump in my left breast” History of the Present Illness without a Complaint The following info is a proposed list of items that can make the HPI complete without the presentation of a complaint Keep in mind that each HPI, as well as PE is tailored to the individual and a set of guidelines is only that
HPI for the Annual Check-up Rectal and Prostate exam for Males. PSA level for all males over 40 – sooner for those with a strong family history. Pelvic exam and PAP smear for females. Breast exam for females. Mammogram for females over 35 years – sooner for those with strong family history HPI for the Annual Check-up Blood work (Complete blood count, Liver function test, Kidney function test, Thyroid test when indicated by history but a must for all women over age 50, Cholesterol testing, C-Reactive Protein, and ferritin blood level). Chest X-rays and CAT scans EKG. Stress testing for everybody over 40 years or over 22 with a positive history or at high risk. Basic Spirometry (if presently smokes or has smoked within 5 years). HPI for the Annual Check-up Flexible sigmoidoscopy with Barium enema if over 40 years or over 30 years with strong family history. Eye examination with particular attention to Glaucoma screening and fundoscopic Appropriate immunizations – (Pneumonia shots, Tetanus, Hepatitis B shots, etc.) when indicated by history. Additional testing may have been indicated for other illnesses if there is a strong family or environmental history.
NUR 378: Health Assessment Across the Lifespan
HPI for the Annual Check-up All risks should be explored: Family history Environmental Stress Tobacco Alcohol Drugs Sexual Diet
HPI for the Annual Check-up If the patient expresses a complaint within the initial HPI questions, then that complaint is explored with CHLORIDEPP, or in similar fashion that we have learned This essentially becomes Part II of the HPI
Tailoring the HPI for Children If the patient is pediatric, the HPI will most likely be given by the guardian It should be stated in the HPI The rest of the HPI contents is age appropriate: Birth history Diet/sleeping Weight stability Daycare/School/grades Immunizations Developmental milestones Extracurricular activities/safety
Format of the PMH MAJOR CHILDHOOD ILLNESSES MAJOR ADULT ILLNESSES – ongoing, sequela, tx HOSPITALIZATIONS – date, reason, complications SURGERIES – dates, reason, outcome, complications ALLERGIES – meds, foods, environ., manifestations IMMUNIZATIONS – up-to-date (peds), flu, pneumovax, hepatitisB, TB, varicella, tetanus for adults MEDICATIONS – all meds: RX or OTC, vitamins, amount and length of time SOCIAL HISTORY OB/GYN HISTORY – menstrual hx, OB hx, BYN hx, screening tests (PAP, mammograms), LMP FAMILY HISTORY
NUR 378: Health Assessment Across the Lifespan
Components of the Social Hx OB/GYN Sexual Marital Status Children Employment Education Religion Hobbies Living conditions Water Supply Alcohol consumption Tobacco Diet Illegal Drug use Military History Beliefs FAMILY HISTORY Should be in diagrammatic or outline form Includes a minimum of 3 generations Includes a negative statement, last If the patient does not know about a relative, then that should be charted as such If the patient is adopted and does not know, that should be charted
The ROS General Integumentary Head Eyes Ears Nose & Sinuses Oral Cavity Respiratory Cardiovascular Gastrointestinal Genitourinary Gynecological Musculoskeletal Neurologic Endocrine Hematologic Psychiatric
NUR 378: Health Assessment Across the Lifespan
Review of the ROS Organized by organ systems in a head-to-toe format. When a positive response is elicited, then further details are asked which will be included in the ROS. It should NOT include signs of disease Each system is listed separately Written as: “Negative for…” or “Patient denies” The Questions for the ROS General – “weight loss or gain, weakness, fatigue, appetite, fever chills, night sweats?” Skin – “rashes, pruritus, bruising, dryness, skin cancer, mole changes or other lesions, changes in hair or fingernails, sun protection, skin cancer” Head – “Trauma, headache, lumps, masses, tenderness, dizziness, syncope ?” Eyes – “Vision, changes in visual field, glasses, last Rx change, photophobia, blurring, diplopia, spots, inflammation, discharge, dry eyes, excessive tearing, history or cataracts or glaucoma?” The Questions for the ROS Ears – Hearing changes, tinnitus (ringing in ears), pain, discharge, vertigo, history of ear infections, last exam?” Nose – Nose bleeds, discharge, colds, hay fever, congestion or sinus problems, PND, trauma, polyps, sense of smell Oral Cavity- Condition of teeth, dentures, plates, last dental check-up, bleeding gums, sore tongue, lesions, ulcers, hoarseness, throat pain or frequent sore throats, swelling, ulcers or lesions
ROS Neck -Stiffness, pain, decreased range of motion, masses, lymph node swelling, enlargement of thyroid Respiratory – Cough, amount and color of sputum (color & amt), dyspnea (difficulty breathing), SOB (includes rest& exertion), wheezing, snoring, sleep apnea, pleuritic pain, frequent pneumonia or bronchitis, influenza or positive PPD? Last chest x-ray? The Questions for the ROS Cardiovascular – Heart trouble, rheumatic fever, HTN, chest pain or pressure, palpitations, breathlessness(orthopnea & PND),diaphoresis, cholesterol, edema, murmurs, leg cramps on exertion (claudication), phlebitis, varicose veins, blood clots? Last EKG? Gastrointestinal – Trouble swallowing (dysphagia), heartburn, nausea, vomiting, hematemesis, indigestion, abdominal pain, PUD, diarrhea, constipation, hemorrhoids, rectal bleeding, change in bowel habits & color (melena), liver problems, food intolerance, frequent flatus, bloating, gallstones. Last rectal exam?
NUR 378: Health Assessment Across the Lifespan
The Questions for the ROS Genitourinary – Frequency, urine stream, urgency, hesitancy, pain, (hematuria), incontinence, frequent infections, History of sexually transmitted diseases, sores, discharge, sterility, impotence, change in urinary stream and color, stones, or hernias? Male: testicular masses, prostate, last exam? Gynecological – Menstrual cycle, PMS, spotting, pain with intercourse (dyspareunia), contraception, breast masses, nipple discharge, self breast examination? Last pap or mammogram? The Questions for the ROS Musculoskeletal – muscle or joint pain, redness, heat, swelling, stiffness, cramping, arthritis, gout, backaches, ROM Neurological – Fainting, blackouts, dizziness, vertigo, syncope, LOC, seizure, weakness, numbness or tingling (pins & needles), stroke, tremors, involuntary movements or gait disturbance, speech, swallowing? Endocrine – Excessive urination (polyuria), thirst (polydipsia), hunger (polyphagia), temperature intolerance (heat & cold), blood sugar, hormone therapy, changes in hair or skin texture? The Questions for the ROS Hematologic – history of anemia, bleeding tendency, easy bruising, sickle cell anemia or trait, lymphadenopathy, ever had a blood transfusion? Psychiatric – anxiety, nervousness, phobias, depression, memory changes or loss, sleep disturbances, suicidal ideation, admissions, sought counseling? Many pts. with unexplained physical complaints suffer from an unrecognized depression or anxiety or maybe victims of abuse Physical Examination – Format General Survey Vital Signs Skin Lymph Nodes Head Eyes Ears Nose Mouth & Throat Neck Thorax & Lungs Breast Peripheral vascular Cardiac Abdomen Genitalia-male/female
NUR 378: Health Assessment Across the Lifespan
Rectum Extremities/Musculoskeletal Neurologic Documenting the General Survey Paragraph form Description of chronological vs. apparent age Gender General state of health Body habitus, grooming/hygiene, dress Sexual development, if appropriate Affect/mood Speech, LOC, signs of distress Documenting the General Survey Mr. X is a well-groomed, tall but thin, 50 yo Caucasian male that looks older than his stated age. Clothing is appropriate for the season. He ambulated with the assistance of a cane and is seated on the exam table with no visual signs of distress. He is smiling and cooperates to answer questions The pt. is alert and oriented to person, place and time.
Documenting Vital Signs All vital signs must be charted: BP, temp, pulse, RR, ht and wt. BP must be charted in terms of which arm and position. All positions and bilateral results, in mm/Hg, need to be present, if able Temperature is documented in Fahrenheit or centigrade units and method of taking it Pulse is charted as bpm (rhythm) (NSR) Respirations as per minute(unlabored, retractions, etc.)
Documenting Integument Color, temperature, turgor/texture, moisture Lesions (color, shape, location & size) Hair (quantity, texture, distribution) Nails (color, shape, lesions) Note and qualify edema (+1-+4) “Skin is warm & dry without cyanosis or jaundice. Edema is +4, pitting, bilaterally on lower extremities. No tenting, rashes, moles, lesions or scars noted. Nail beds are pink, without clubbing bilaterally” Documenting the Head Symmetry, shape, trauma Hair distribution Tenderness, step offs, masses Fontanel’s in babies Parotid glands
NUR 378: Health Assessment Across the Lifespan
Facial features Palpation of sinuses
Documenting the Head “Normocephalic, atraumatic. Hair is thick and closely cropped. No scalp lesions, lice or nits. Facial features are symmetrical without nasolabial fold flattening. No parotid gland enlargement, scalp tenderness, step offs or masses. No frontal or maxillary sinus tenderness to percussion, bilaterally. ROM of TMJ without click or pain, bilaterally”
Documenting the PE Lymph Nodes – size, mobility, tenderness, consistency of all cervical,(list the neck nodes separately) supraclavicular, axillary, epitrochlear, inguinal nodes noted. Eyes – symmetry, condition of lashes & brows, lacrimal apparatus & canal; PERRLA, EOM’s, visual fields, visual acuity (OS,OD,OU), and chart used, nystagmus, ptosis, discharge, sclera and conjunctiva. Fundoscopic exam, Red Reflex, fundus, (exudates, papilledema, AV nicking or hemorrhages) noted
Example of Eye Documentation “Symmetric alignment of eyes & brows. Sclera white without injection. Bulbar & palpebral conjunctivae pink, without lesions or ulcers. Cornea & iris are clear. EOM full & equal. No lid lag or nystagmus. Visual acuity with Snellen chart, 20/20 os, od, & ou without needed correction. Eye exam performed bilaterally” Example of Eye Documentation Fundoscopic exam: “Performed without pharmacological mydriasis. Bilaterally noted: red reflex present, no a-v nicking, hemorrhages, lens opacities, disk cupping, papilledema, cotton wool spots or other pathologies.”
EARS Ears – Inflammation, masses, lesions of auricles & pinna External canals, discharge, cerumen.TM color & state (dull, shiny, perforation, injection, bulging, light reflex), landmarks, auditory acuity (Whisper test, Weber & Rinne results) Must mention all “bilaterally” EARS “ No lesions, masses or inflammation of pinna or auricles noted. No pain to palpation of auricle or tragus. Bilateral external canals without noted redness, inflammation, cerumen or discharge. Whispered word is repeated from—feet/inches. Otoscopic exam notes intact TM with + cone of light, pearly gray color. No bulging, erythema, d/c air-fluid level, bilaterally.”
Documenting the PE Nose – patency, septal deviation or perforation, mucosal color, discharge, exudates, nasal flaring Mouth & Throat – mucus membrane color & moisture level; oral lesions, dentition, tongue protrudes in midline, pharyngeal color or lesions. Stenson’s & Wharton’s ducts, uvula.
NUR 378: Health Assessment Across the Lifespan
Neck – Supple, stiffness, ROM, JVD, carotids, thyroid, trachea midline, nodes, bruits, masses Thorax & Lungs – symmetrical, use of accessory muscles, retractions, respiratory excursion, AP diameter, tenderness, fremitus, percussion, auscultation, rhonchi, crackles, rubs Documenting for the NOSE “ Nasal patency bilaterally. Septum mid-line. No nasal flaring. Mucosa and turbinates are well perfused, pale-pink in color and moist. No lesions, ulcers bleeding, polyps or nasal discharge, bilaterally”
Documenting the Neck “Supple with full ROM. Trachea midline. Carotids +4 and no bruits. JVD pressure 3 cm. at 30 degrees. No thyroidmegaly, masses or nodules palpable” Lymph nodes can be listed here with findings, if you chose NOT to have a separate category for them but must remember to include them in each system where appropriate
Documenting the Breast Exam Breasts – size, symmetrical, masses, tenderness, contour & consistency, retractions, dimpling, gynecomastia (males), nipple discharge, areola, axillary nodes R and L Here you can draw a picture if needed to describe a location
Example of a Breast Exam Note “Chest wall appears symmetrical. No gynecomastia, nipple discharge, lesions, retractions, masses or tenderness to palpation. No axillary or epitrochlear lymphadenopathy noted , bilaterally. Pt. Examined supine, hands over head , on hips and leaning forward.”
Documenting the Heart Cardiovascular – Note heaves, lifts, thrills, PMI, RRR, S1, S2, splitting, murmurs, gallops (S3, S4). “PMI visible @ the 5th ICS/MCL. No lifts heaves or thrills. Heart rate is 72 bpm with sinus rhythm. S1, S2 audible throughout, without splitting. No S3, S4, rubs gallops or clicks. No noted murmurs in supine, leaning forward or left, lateral decubitus position” Documenting the Abdomen Abdomen – describe contour (flat, scaphoid, obese, distended, protruberant), any scars, bruises, stretch marks, etc.bowel sounds present (active, hyperactive, hypoactive, absent) all quadrants, ascites, tenderness, masses, liver span by percussion (location), splenic percussion sign, splenomegaly, palpable kidneys, guarding, rebound tenderness, CVAT, hernias
NUR 378: Health Assessment Across the Lifespan
Example of the Abdominal Documentation “Flat without visible scars, hernias, ecchymosis, peristalsis, pulsations or venous distention. Normoactive bowel sounds in all 4 quadrants. No aortic, renal , iliac, or femoral bruits noted. Liver span 8 cm/MCL with smooth edge. Gall bladder and spleen not palpable. No noted tenderness on light or deep palpation in any quadrant. No masses guarding or rebound. No CVAT.””
Genitalia Males-circumcised, lesions, inflammation, meatus, testes for descent, symmetry, masses, inguinal hernias, inguinal nodes Females- external (hair distribution, shaven, tatoos, piercings, moles etc)
External gentitalia (Bartholin’s, urethra, Skenes’s glands (BUS), clitoromegaly; labia major, labia minora.
Vagina – tone, pelvic relaxation (cystocele, urethrocele, rectocele), discharge (color, odor, consistency), lesions, well estrogenized vs. hypoestrogenic / atrophic
Cervix – nulliparous / parous, ectropion, eversion, Nabothian cysts, polyps, color, discharge (color), lesions, any cervical motion tenderness
Uterus – size, shape, consistency, position; i.e., anteverted, anteflexed, mid-position, retroverted, retroflexed),
Adnexa: note right and left separately: palpable or not palp, tenderness, masses
Rectal – hemorrhoids, fissures, fistulae, sphincter tone, stool in rectal vault, test for occult blood
Testes: descended, (nodules, tenderness and texture), masses
Prostate (size. nodules, tenderness and texture), masses,
How to Chart Pulses Peripheral Vascular – skin color, edema, varicose veins, bruits peripheral pulses (O-4+): Peripheral Vascular (0 – 4+): Radial Femoral Popliteal D. Pedis P. Tibialis Right 2+ 2+ 1+ 2+ 2+ Left 2+ 2+ 1+ 2+ 2+
NUR 378: Health Assessment Across the Lifespan
MUSCULOSKELETAL For each joint note: obvious deformities i.e. amputation, scoliosis, lordosis, kyphosis swelling (tumor) redness (rubor) increased temperature (calor) tenderness (dolor) crepitus limitation of range of motion
Note for the Musculoskeletal Exam Extremities – Homan’s sign, cyanosis, varicosities, hair growth or absence, if not noted prior, any specialized ortho testing and the results/findings Muscle strength, graded as 5/5 in all extremities, bilaterally (This is usually placed in the neuro exam) 0=no contraction, 1=barely, 2=active w/o gravity, 3=active against gravity, 4=active against gravity w some resistance, 5=active against full resistance Format for the Neuro Exam Mental status Motor system Sensory DTR Cranial nerves (1-12) Mental Status “Alert and oriented to person, time and place.” A formal mental status exam would be charted here “No confusion, agitation, or anxiety noted” Motor “Muscle strength 5/5 in all extremities bilaterally” “Gait steady w/o ataxia” Finger-to-nose, Rhomberg and station, heel to toe walking, walking on heels and toes, heel to shin and pronator drift “all performed bilaterally without deficit” Sensory Sharp, dull, light & temperature- “all dermatomes tested without deficit” Can also list the dermatomes Vibratory sense, joint position Graphesthesia & stereognosis Two point discrimination & extinction A Way to Document Reflexes Neurologic: R L Triceps 2+ 2+ ++ Biceps 2+ 2+ Brachioradialis 2+ 2+ ++ Patellar 2+ 2+ Ankle 1+ 1+ Babinski absent bilaterally
NUR 378: Health Assessment Across the Lifespan
Results could also be documented as a stick figure Cranial Nerves List the number of each nerve, then describe the findings CN 1- “Able to identify scent of coffee and cloves.” CN II- “Visual acuity with the Rosenbaum chart, without correction: 20/20 OS, 20/20 OD, 20/20
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