Intro to Clinical Assessment & Head-to-Toe Approach Flashcards
Vital signs
- Temp
- Heart rate
- Respiratory rate
- Blood Pressure
-Height - Weight
Psychiatric (Psych)
- 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
Neurological (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
What does DERM include?
- Skin
- Hair
- Nails
Skin hair and nails
Rashes
Bruises
Dryness or moistness
Itching
Hair loss or growth
- Lesions, masses, ulcers, sores, wounds
- Changes in hair or nails
- Changes in skin colour (ex. erythema), texture
- Changes in mole colour, texture, size
HEENT
Head, ears, eyes, nose, throat
Head and neck
Pain or headache
Dizziness
Light-headedness
Fainting spells
Swollen glands
Eyes
Visual acuity
Pain
Spots, specks, flashing lights
Double or blurred vision
Tearing or dryness
Itching
Redness
Discharge
Blind spots
Ears
Auditory acuity
Tinnitus
Vertigo
Earaches
Disharge
Nose and Sinuses
Itchiness
Nasal congestion
Discharge or runny nose
Nosebleeds
Sinus pain or pressure
Throat and Mouth
Gum sorenesss and sore throat
Mouth or tongue sores
Bleeding gums
Dry mouth
Hoarseness of voice
Loss of taste
Condition of teeth and gums
Use of dentures
Respiratory
Difficulty breathing
Pain on breathing
Dyspnea - shortness of breath
Cough
Wheezing
Sputum - Saliva and mucus coughed up
Hemoptysis - Coughing up blood
Snoring or apnea
Chest wall abnormalities
Chest pain or chest tightness
Cardiovascular
Rapid or irregular heart beat
Palpitations or flutters
Chest pain or pressure
High or low blood pressure
- Orthostatic hypotension - BP suddenly drops when you stand
Heart murmur - extra noise during heart beat
Gastrointestinal
Difficulty or pain on swallowing
Heartburn, acid reflux
Changes in appetite
Nausea
Vomiting
Abdominal pain
- Hematemesis - significant amount of blood in vomit
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
Freq. of urination
- Polyuria - urinate more than normal
- Nocturia - Need for patients to get up at night on a regular basis and urinate
- Anuria - Failure of kidneys to produce urine
Urgency or dribbling
Burning or pain during urination
Hematuria - Blood in urine
Kidney or flank pain
Enlarged prostate
- Dysmenorrhea - pain with menstruation
Menstrual regularity and freq.
Vaginal dryness or itching
- Changes in sexual interest & function
Discharge or sores
Peripheral vascular system
Temperature change (e.g. cold or warm extremities)
* Discolouration (e.g. cyanosis, pallor)
* Leg cramps
* Varicose veins
* Pain or numbness
* Edema or swelling
* Erythema
* Tenderness
* Reduced pulses
List the steps to a clinical assessment
- History taking
- Physical exam
- Develop working diagnosis
- Obtain lab studies
- Develop final diagnosis
- Initiate treatment
- Ongoing evaluation
What 9 steps of a comprehensive health history invovle?
1) Identifying data (ID)
2) Chief concern/complaint (CC)
3) History of present illness (HPI)
4) Past medical history (PMHx)
5) Medication history (MHx)
6) Allergies & intolerances
7) Family history (FHx)
8) Social history (SHx)
9) Review of systems (ROS)
1) Identifying data (ID)
Date and time of history
* Age, gender identity/pronouns, occupation, marital status
Chief complaint (CC
The symptoms causing the patient to seek care
* Quote patient’s own words
History of present illness (HPI)
Complete, clear, chronologic account of presenting problem
* Detailed description of symptoms, treatments & risk factors
Past medical history (PMHx)
Medical, surgical, obstetric/gynecologic, psychiatric
* Immunizations
Medication history (MHx)
Prescription and non-prescription medications; vitamins and
supplements; alternative health products
Allergies and intolerances
Date of reaction, symptoms of reaction
Family history (FHx)
Presence or absence of specific illnesses
Social history (SHx)
Education level, ethnicity, current home situation, support system,
personal interests, lifestyle (smoking, alcohol, illicit drugs), activities
of daily living, exercise, diet
Review of systems (ROS)
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 a patient-centered approach (vs. a product-centered
approach)
Order of ROS
VS
PSYCH OR NEURO
DERM
HEENT
RESP
CV
GI
GU
PVS
MSK
What does scholar stand for?
Symptoms
Characteristics
History
Onset
Location
Aggravating Factors
Remitting Factors
Symptoms
What are the main & associated symptoms
Characterists?
What are the symptoms like?
History
What has been done so far? 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 you ask in your ROS should be based on…
Patient History
Best way to assess new patients
Comprehensive
Provides fundamental knowledge about patients
Comprehensive
Helps identify or rule out physical causes related to patient
Comprehensive
Strengthens pharmacist-patient relationship
Comprehensive
Efficient way to assess established patients
Focused
Addresses specific concerns and symptoms
Focused
Assesses symptoms restricted to a specific body system
Focused
Applies examination methods relevant to assessment of target problem
Focused
