Adult Assessment Flashcards
What is the first step in taking a patients history?
Obtain the patients chief complaint in their own words.
Once you determine the chief complaint what is the next step in the history?
HPI: Try to present a clear account of the patients chief complaint including what treatments have been tried, what worked and what didn’t?
What acronym helps you remember the HPI?
OLD CART
“O”
Onset: where and when
“L”
Location: where is the location of the symptoms?
“D”
Duration: how long has this been going on, do the symptoms come and go?
“C”
Characteristics: describe the symptoms more
“A”
Any aggravating factors: does anything make the symptoms worse?
“R”
Relieving factors: does anything make it better?
“T”
Treatment: what treatments have been tried?
Once you have completed the HPI, what is the next step in the history?
Past Medical History (PMH)
What follows past medical history?
Past surgical history
What follows past surgical history?
Family Medical history
What follows Family Medical history?
Lifestyle: Diet, exercise, sleep, tobacco/alcohol/illicit substances, Employment status, living arrangements, seatbelt use, religion
What follows lifestyle?
Medications: OTC, inhalers, eye drops, herbal supplements, vitamins, home remedies/cultural treatments.
What follows medications?
Allergies: Allergen and reaction
What follows allergies?
Immunizations: Influenza, pneumococcal, shingles, TB
What follows immunizations?
Review of systems
General ROS
Fever/chills, fatigue, unexplained weight changes, sleep difficulties, diaphoresis, night sweats
Eyes ROS
Blurred vision, double vision, eye pain, discharge/increased tearing, deviation
Nose ROS
Nose bleeds, stuffiness/congestion, nasal discharge, sinus pain
Mouth ROS
Lesions/ulcers, pain, tooth loss/cavities, altered taste
Throat ROS
Difficulty swallowing, sore throat, voice changes/loss, hoarseness, >2 head colds/year
Respiratory ROS
SOB, cough, wheezing, paroxysmal nocturnal dyspnea, dyspnea on exertion, hemoptysis, orthopnea
Breast ROS
Changes in skin texture, pain, dimpling, masses/changes in consistency
Cardiac ROS
Chest pain, murmurs, palpitations, elevated BP, irregular heart beat
Circulatory ROS
Cool extremities, varicose veins, thrombosis, claudication, peripheral edema
GI ROS
Dysphagia, heartburn, bloating, eructation, changes in bowel habits, diarrhea, vomiting, constipation, bloody stools
Urinary ROS
Frequency, dysuria, hematuria, hesitancy, flank pain, urinary urgency, incontinence
Reproductive female ROS
LMP, menopause, irregular bleeding, vaginal discharge, painful intercourse, contraception, partners (gender/#), STD’s
Reproductive Male ROS
Testicular pain/lesions, erectile dysfunction, STD’s, penile discharge, hematospermia, partners (gender/#)
Musculoskeletal ROS
Joint stiffness, swelling, redness, bone deformity, back/neck pain, weakness
Neuro ROS
Dizziness, headache, localized/general weakness, numbness, memory changes/loss, parasthesias, speech changes, gait changes
Skin ROS
Changes in pigmentation, changes in moles, new moles, itching, rashes, changes in skin texture, hair texture, changes in nails
Mental/emotional ROS
Depression, anxiety, suicidal ideation, difficulty concentrating, stressors, memory loss, hallucinations
Heme/endo ROS
Enlarged lymph nodes, anemia, syncope, bruising easily, clotting disorders, polydipsia, polyphagia, heat/cold intolerance
General Appearance-physical assessment
Grooming, dressing, facial expression, symmetry of movement, skin color/turgor. Appears acutely ill, s/s of dehydration (dry mucous membranes, tachycardia, dizziness), cyanosis/pallor, sob/use of accessory muscles to breath, drooling.
Vital signs
BP, pulse, temp, respirations, weight, height, BMI
Check postural changes, lying, sitting, standing.
How do you check postural changes (orthostatic vitals)?
Check VS lying, sitting, then standing. Wait 2-5 minutes following posture change and recheck vitals. With postural changes you will see >20 mmHg drop in systolic BP, >10 mmHg drop is diastolic BP, patient becomes symptomatic (dizzy)
What does low diastolic BP indicate?
<65 mmHg implies decreased peripheral resistance or aortic valve regurgitation (which is significant, even if the heart sounds are not loud)
Inspect skin PHYSICAL
Fingernails for clubbing, suspicious or unusual lesions
Head PHYSICAL
Inspect the face and head, palate the scalp, temporal area for pulsation and mass ether muscle (have patient clench teeth)
