Adult Complete Health Assessment (Final)

Question 1

Sequence of Examination

Answer 1

1. obtain health history
2. observe general appearance
3. obtain measurements
4. examine skin
5. vitals
6. inspect, palpate and auscultate

Question 2

Inspect and Palpate

Answer 2

1. head and face
2. eyes and ears
3. nose, mouth, throat and neck
4. chest
5. heart
6. UE
7. breasts and neck vessels
8. abdomen and inguinal area
9. LE
10. MSK
11. neurologic
12. genitalia and rectum

Question 3

Biographic Data

Answer 3

source
reason for seeking care
history of present illness

Question 4

Past Health

Answer 4

illnesses
accidents
last exam
allergies
meds

Question 5

Family History

Answer 5

genogram

Question 6

Review of Symptoms

Answer 6

general health
all body systems

Question 7

Functional Assessment

Answer 7

activity
exercise
sleep
nutrition
alcohol
smoking
support
coping and stress

Question 8

Perception of Health

Answer 8

own feelings about health
generally interest in health status

Question 9

Measurements

Answer 9

height/weight/weight circumference/BMI
vital signs
vision (snellen eye chart, CN II)

Question 10

Head and Face

Answer 10

inspect and palpate scalp, hair, cranium
inspect facial symmetry, expression, CN VII
palpate temporal artery then temporomandibular joint as person opens and closes mouth
palpate maxillary and frontal sinuses

Question 11

Inspecting External Eye Structures

Answer 11

conjunctiva
sclera
corneas
irises

Question 12

Ears

Answer 12

inspect external ear for position and alignment, skin condition, auditory meatus; move auricle and push tragus for tenderness
test hearing (whispered voice test)
otoscope (inspect canal, then tympanic membrane for color, position, landmarks and integrity)

Question 13

Inspecting nares with…

Answer 13

a speculum

Question 14

Mouth and Throat

Answer 14

inspect mouth with light (buccal mucosa, teeth and gums, tongue, floor of mouth, palate, uvula) GRADE TONSILS IF PRESENT
test gag reflex, CN IX AND X, XII
bimanually palpate mouth if indicated with glove

Question 15

Neck

Answer 15

inspect neck
palpate cervical lymph nodes
palpate carotid
palpate trachea
test ROM and strength, CN XI
palpate thyroid

Question 16

Anterior Chest

Answer 16

inspect respirations and skin
palpate for tactile fremitus, lumps, tenderness
percuss anterior lung fields
auscultate

Question 17

Posterior and Lateral Chest

Answer 17

inspect configuration of thoracic cage, skin, and symmetry of shoulder and muscles
palpate for symmetric expansion, etc. and length of spinous processes
percuss all lung fields, costovertebral angle noting tenderness
auscultate

Question 18

Heart

Answer 18

ask person to lean forward and exhale briefly, ascultate for murmurs
inspect precordium for pulsations and heaves
palpate apical pulse, precordium for thrill
auscultate apical rate and rhythm
turn person to left to auscultate with bell

Question 19

UE

Answer 19

test ROM and strength
palpate epitrochlear nodes
palpate temp and cap refill
compare radial and brachial pulses bilaterally

Question 20

Breasts

Answer 20

inspect symmetry, mobility, and dimpling as she lifts arms/leans forward and pushes hands on hips; supra and infraclavicular areas
palpate each breast including tail of spence and areola, nipple for discharge
palpate axilla and lymphs
self exam

Question 21

Male Breasts

Answer 21

inspect and palpate anterior chest wall
palpate axilla and lymph

Question 22

Neck Vessels

Answer 22

inspect each side for jugular venous pulse, turning persons head slightly to the side
estimate jugular venous pulse if indicated

Question 23

LE

Answer 23

inspect legs for varicose veins

Question 24

MSK

Answer 24

ask person to walk normally away and towards you, heel-to-toe
ask person to walk on toes for few steps, then heels for few steps
check for romberg
ask person to hold edge of bed and perform shallow knee bend for each leg
stabilize pelvis and test ROM of spine as person hyperextends, rotates and laterally bends

Question 25

Neurological

Answer 25

test sensation (*superficial pain, light touch, vibration*) position sense of finger, one hand stereognosis cerebellar function of UE using finger to nose test or rapid alternating movements cerebellar function of LE by asking person to run each heel down opposite shin deep tendon reflexes babinski

Question 26

Inguinal Area

Answer 26

palpate each groin for femoral pulse and inguinal nodes; lift drape to expose legs

Question 27

LE

Answer 27

palpate popliteal, posterior tibial and dorsalis pedis pulses separate toes and inspect test ROM and strength (ask person to sit on edge of bed and dangle legs)

Question 28

Genitalia and Rectum

Answer 28

male (inspect, palpate scrotal contents; transilluminate if mass exists, check for inguinal hernia, teach TSE) female (inspect perineum and perineal areas) rectum (inspect perianal area, save stool specimen for occult test)