IMM 02: Introduction to Clinical Assessment & Head-to-Toe Approach Flashcards
What are the steps involved in conducting a clinical assessment? (7)
- history taking
- physical exam
- develop working diagnosis
- obtain lab studies
- develop final diagnosis
- initiate treatment
- ongoing evaluation (follow-up)
What are the components of a comprehensive health history? (9)
(might not go through everything for every patient)
- identifying data (ID)
- chief concern/complaint (CC)
- history of present illness (HPI)
- past medical history (PMHx)
- medication history (MHx)
- allergies and intolerances
- family history (FHx)
- social history (SHx)
- review of symptoms (RS)
Identifying Data (ID)
What information is classified here? (2)
- date and time of history
- age (risk factor), gender identity/pronouns, occupation (risk factor), marital status (support system)
Chief Concern/Complaint (CC)
What information is classified here? (2)
- symptoms causing the patient to seek care
- quote patient’s own words
History of Present Illness (HPI)
What information is classified here? (2)
- complete, clear, chronologic account of presenting problem
- detailed description of symptoms, treatments, and risk factors
Past Medical History (PMHx)
What information is classified here? (2)
- medical, surgical, obstetric/gynecologic, psychiatric
- immunizations
Medication History (MHx)
What information is classified here? (1)
prescription and non-prescription medications, vitamins and supplements, alternative health products
Allergies and Intolerances
What information is classified here? (2)
- date of reaction
- symptoms of reaction
Family History (FHx)
What information is classified here?
presence or absence of specific illnesses
Social History (SHx)
What information is classified here?
- education level
- ethnicity (prevalence of condition)
- current home situation
- support system
- personal interests
- lifestyle (smoking, alcohol, illicit drugs)
- activities of daily living
- exercise
- diet
- some conditions are more prevalent within certain ethnicities
- important to not make assumptions
Review of Symptoms (RS)
What information is classified here?
documents presence or absence of common symptoms related to each major body system
- detailed, systematic, and complete review of a patient’s symptoms
- organizes information head-to-toe according to major body systems
- takes patient-centred approach (vs. product-centred approach)
What are the components of a head-to-toe review of systems? (10)
- vital signs (VS)
- psychiatric (PSYCH) and neurologic (NEURO)
- skin, hair, nails (DERM)
- head, ears, eyes, nose, throat (HEENT)
- respiratory (RESP)
- cardiovascular (CV)
- gastrointestinal (GI)
- genitourinary (GU)
-peripheral vascular system (PVS) - musculoskeletal (MSK)
Vital Signs (VS)
- temperature
- heart rate
- respiratory rate
- blood pressure
- height
- weight
Psychiatric (PSYCH)
(can be a result of side effects of certain drugs)
- insomnia
- nervousness or anxiety
- changes in insight, orientation, memory, or judgement
- changes in attention or mood
- unusual or disturbing thoughts
- hallucinations or delusions
- suicidal thoughts or attempts
Neurologic (NEURO)
- headache
- dizziness or vertigo
- weakness or paralysis
- numbness or loss of sensation, tingling or ‘pins and needles’
- change in level of consciousness (LOC)
- tremors or other involuntary movements
- convulsions or seizures
- rigidity
Skin, Hair, Nails (DERM)
- rashes
- bruises
- dryness or moistness
- itching
- hair loss or growth
- lesions, masses, ulcers, sores, wounds
- changes in hair or nails
- changes in skin colour (ie. erythema), texture
- changes in mole colour, texture, size
Head and Neck (HEENT)
- pain or headache
- dizziness
- light-headedness
- swollen glands
Ears (HEENT)
- auditory acuity
- tinnitus
- vertigo
- earaches
- discharge
Eyes (HEENT)
- visual acuity
- pain
- spots, specks, flashing lights
- double or blurred vision
- tearing or dyrness
- itching
- redness
- discharge
- blind spots
Noses and Sinuses (HEENT)
- itchiness
- nasal congestion
- discharge or runny nose
- nosebleeds
- sinus pain or pressure
Throat and Mouth (HEENT)
- gum soreness or sore throat
- mouth or tongue sores
- bleeding gums
- dry mouth
- hoarseness of voice
- loss of taste
- condition of teeth and gums (ie. cavities)
- use of dentures
Respiratory (RESP)
- difficulty breathing
- pain on breathing
- dyspnea
- cough
- wheezing
- sputum
- hemoptysis
- snoring or apnea
- chest wall abnormalities
- chest pain or chest tightness
Cardiovascular (CV)
- rapid or irregular heart beat
- palpitations or flutters
- chest pain or pressure
- high or low blood pressure
- orthostatic hypotension
- heart murmur
Gastrointestinal (GI)
- difficulty or pain on swallowing
- heartburn, acid reflux
- changes in appetite
- nausea
- vomiting
- abdominal pain
- hematemesis
- excessive belching or gas
- diarrhea
- constipation
- change in bowel habits
- pain on defecation
- rectal bleeding
- blood in stools or black/tarry stools
- hemorrhoids
- jaundice
Genitourinary (GU)
- frequency of urination
- polyuria, nocturia, anuria
- urgency or dribbling
- burning or pain during urination
- hematuria
- kidney or flank (lower back) pain
- enlarged prostate
- dysmenorrhea
- menstrual regularity and frequency
- vaginal dryness or itching
- changes in sexual interest and function
- discharge or sores
Peripheral Vascular System (PVS)
- temperature change (ie. cold or warm extremities)
- discolouration (ie. cyanosis, pallor)
- leg cramps
- varicose veins
- pain or numbness
- edema or swelling
- erythema
- tenderness
- reduced pulses
Musculoskeletal (MSK)
- muscle cramps or pain
- joint pain or tenderness
- joint swelling or redness
- joint stiffness
- muscle weakness
- deformities
What are the attributes of a system? (7)
SCHOLAR
- symptoms – what are the main and associated symptoms
- characteristics – what are the symptoms like
- history – what has been done so far, has it happened in the past
- onset – when did it start
- location – where is the problem
- aggravating factors – what makes it worse
- remitting factors – what makes it better
What are the steps of conducting a review of symptoms? (3)
- prepare the patient
- explain why you are performing ROS
- ensure patient comfort and privacy
- start with general open-ended questions pertaining to each body system
- ie. do you have any trouble with your heart, do you ever experience any headaches
- ask more specific questions (SCHOLAR) as you uncover information
- ie. where is the chest pain located, does anything make your headaches worse, have you taken any medications that help alleviate the headache
How do you use a review of symptoms?
as you ask questions from head-to-toe, consider:
- could this symptom be caused by the patient’s medication(s)
- does presence of this symptom suggest that the patient’s medication is effective or ineffective
- does presence of this symptom suggest an undiagnosed condition
- how do all of the symptoms my patient is experiencing relate to each other
- what does this symptom tell me about the patient’s overall health status
remember that what you ask in your ROS should be based on your patient history
What is a comprehensive assessment? (4)
- best way to assess new patients
- provides fundamental knowledge about patient
- helps identify or rule out physical causes related to patient concerns
- strengthens pharmacist-patient relationship
What is a focused assessment?
- efficient way to assess established patients
- addresses specific concerns and symptoms
- assesses symptoms restricted to a specific body system
- applies examination methods relevant to assessment of target problem
