``` i. Previous heart problems? Yes___ No___ If yes, what kind? Heart defect? ____________________ Murmur? _________________ Heart attack? ________________ ``` 4. Family History i. Hypertension? Yes___ No___ ii. Myocardial Infarction? Yes___ No___ iii. Coronary Heart Disease? Yes___ No___

Validation 2 Flashcards by Victoria Rain

what do you do when you enter a pt. room?

wash hands
introduce self (full name and pronouns)
ask pt. full name, preferred pronouns, and preferred way of being addressed
obtain pt. birth date
explain what we will be doing today
ask chief complaint

“Hi my name is…
“Could you tell me your full name, preferred pronouns, and date of birth please?”
“And how would you like me to address you today?”
“Today we will be doing a focused assessment on you. The plan is to ask questions about health history and then move onto the physical exam. I will be talking out loud for my instructor”
“Can you tell me what brings you in today?”

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Asks at least 3 HPI (History of Present Illness) or symptom analysis questions related to chief complaint

Character (How does it feel?) ___________
Onset (When did it begin?) ____________________
Location (Where is it? Does it radiate/move?) ____________________
Duration (How long does it last? Does it come and go?) __________________________
Severity (How bad is it if you are to rate it on a scale of 0 to 10? 0 being no pain, 10 being the worst pain you’ve ever felt) ___________________________________________
Pattern (Does anything make it better? Medications?) ____________________________
(Does anything make it worse?) ______________________________
Associated factors (What other symptoms (nausea/vomiting/diarrhea, loss of vision/light sensitive, cough/wheezing/shortness of breath) do you have with it?) ______________________
(Does it affect your work and/or activities?) ____________________

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PMH

Respiratory

• Any respiratory problem in the past?
• Previous thoracic trauma, surgery, or biopsy?
family history of respiratory issues?

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PMH

i. Previous abdominal surgery? Yes___ No___
v. Abdominal pain? Yes___ No___
ii. Trauma or injury? Yes___ No___

Family History of Abdominal Disorders?

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PMH

Cardiovascular

i.	Previous heart problems? Yes\_\_\_ No\_\_\_
If yes, what kind?
Heart defect? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 
Murmur? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 
Heart attack? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Family History
i. Hypertension? Yes___ No___
ii. Myocardial Infarction? Yes___ No___
iii. Coronary Heart Disease? Yes___ No___

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Ask at least 2 allergy or medication questions

“Are you allergic to medications (prescription, OTC, or herbal supplements)?”
“Do you have any seasonal or food allergies?”

If yes,
“What symptoms are associated with your allergic reaction?”
“When was the last time you experienced an allergic reaction?”

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Asks at least 3 pertinent Review of System (ROS) questions related to reason for
GI

Gastrointestinal-
Any Nausea and/or Vomiting? ____ How often? __ Description? ___ Any blood? ____
Diarrhea? ______ How often? _______ Description? ______ Any blood? ________
Any problems with indigestion, heartburn, bloating, or gas? _________
Any weight loss or gain? _____________ Was it intentional? ___________
Any change in what you are eating? ____________

Urinary-
Any change in frequency of urination? _________
Any burning sensations when you urinate? ______
Any loss in bladder control? ________

Cardiovascular-
Any SOB? ______
Any chest pain? _____
Any feeling of fluttering in the chest? _______

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Asks at least 3 pertinent Review of System (ROS) questions related to reason for
Respiratory

Respiratory-
Cough _____ Sputum (color, quantity) ______ Hemoptysis (cough up blood) _______
Dyspnea (difficulty/labored breathing) ________ Wheezing ________

Cardiovascular-
Any SOB? ______
Any chest pain? _____
Any feeling of fluttering in the chest? _______

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Asks at least 3 pertinent Review of System (ROS) questions related to reason for
cardiovascular

Cardiovascular-
Any SOB? ______
Any chest pain? _____
Any feeling of fluttering in the chest? _______
HTN? ____
Have you noticed any swelling in your arms/legs? ______

GI-
Any problems with indigestion, heartburn, bloating, or gas? _________
Any weight loss or gain? _____________ Was it intentional? ___________
Any nausea and/or vomiting? ______

Respiratory-
Cough ______ Sputum (color, quantity) _____ Hemoptysis (cough up blood) _______
Dyspnea (difficulty/labored breathing) ________
Wheezing ________

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Asks at least 2 environmental/risk factors questions related to reason for
GI

Cause of stress in life; effect on eating and elimination patterns?
Around any toxins based upon job/home/school?

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Asks at least 2 environmental/risk factors questions related to reason for
Cardiovascular

Life Stress?  Yes\_\_\_ No\_\_\_
     Type: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 
Usual diet patterns? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Usual exercise pattern?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Sleep routine? (Does pt. feel rested?)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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Asks at least 2 environmental/risk factors questions related to reason for
Respiratory

Do you smoke- Chew- or Snuff tobacco?
If pt. has quit- how long ago? ___
Any Exposures to other environmental hazards, such as Second-hand Smoke or Asbestos?____
Any difficulty performing activities of daily living?

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Vital signs assessment

HR, BP, Pain, RR, Temperature, Height and Weight
(If no temperature probes- “at this point I would take your temperature, but we don’t have anything to do so.”)

After assessing, let pt. know what their vitals are and let them know the normal values
“This was what your ___. The normal range is __.”

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Normal BP Range

Systolic BP 100-119

Diastolic BP 60-79

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Normal Temperature Range

Oral: 35.8°C – 37.3°C (96.4°F – 99.1°F)

Rectal and tympanic: 36.1 - 37.9°C (97°F - 100.2°F)

Axillary and temporal: 35.2 - 37.0°C (95.4°F - 98.6°F)

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Normal HR Range

50-95 beats per minute

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Normal RR Range

10-20 rpm

Normal Pain Range

No “normal”; often desired “no pain”, but may not be “normal”

Respiratory Assessment Order

Inspection
Palpation
Percussion - anteriorly start above clavicles and go down intercostally, laterally in 3 locations comparing each side, posteriorly start above scapula and go down intercostally avoiding bone
Auscultation

If pt. is laying down during physical exam, NEED to support the legs*
ASK pt. to raise or lower gown*

Be sure to have pt. report any pain during palpation and percussion

GI Assessment Order

Inspection
Auscultation - start RLQ and work around - listen for 5 sounds and move on
Percussion - abdomen, liver, spleen, kidneys
Palpation - light then deep palpation- look at pt. face while palpating (skip or palpate last the areas that have pain)

If pt. is laying down during physical exam, NEED to support the legs*
ASK pt. to raise or lower gown*

Be sure to have pt. report any pain during palpation and percussion

Cardiovascular Assessment Order

Inspection
Palpation
Auscultation

If pt. is laying down during physical exam, NEED to support the legs*
ASK pt. to raise or lower gown*

Be sure to have pt. report any pain during palpation and percussion

Auscultate carotid pulses

with diaphragm then the bell of stethoscope

ask pt. to hold breath

listen to 5 points of the heart

(APeTM) Aortic, Pulmonic, Erb’s, Tricuspid, Mitral
S2 louder at A and P; S1 louder at T and M

Listen with diaphragm then the bell

Perform Allen test

occlude the radial and ulnar vessels- observe palm pallor - release ulnar to watch color come back to hand

Capillary refill

done on fingers and toes press and release nails to see the pallor and color come back - should be less than 2 seconds

Tactile fremitus

With the ball or ulnar edge of one hand, palpate for fremitus, while the patient says “ninety-nine” and assess for symmetry and intensity of vibration posteriorly and anteriorly

Chest expansion

Placing your hands on the patient’s posterior chest and both thumbs at level of T9 or T10, observe the movement of your thumbs while the patient takes deep breaths. Check the movement of thumbs while the patient perform deep breathing exercise.

Bronchophony

ask the patient to say “ninety-nine” after stethoscope touches skin anteriorly and posteriorly in 6 locations

Egophony

ask the patient to say letter “E” after stethoscope touches skin anteriorly and posteriorly in 6 locations

Whispered pectoriloquy

ask the patient to whisper the phrase “one-two-three” after stethoscope touches skin anteriorly and posteriorly in 6 locations

CVA tenderness (blunt percussion)

Place nondominant hand on back (kidney) then make fist with dominant and strike nondominant hand *tell pt. to alert if any pain*

McBurney sign

Touching RLQ to see if any pain with pressing (where hand is) for appendicitis

Aaron sign

Pressing on RLQ but pain is felt in epigastric region for appendicitis

Rovsing’s sign

Press on LLQ but pain is felt in RLQ for appendicitis

Obturator sign

Lift R leg up; 90 degrees bent knee and rotate ankle externally and internally for appendicitis

Psoas sign

Lift leg straight up and push down on knee- ask if pain is felt for appendicits

Referred rebound tenderness (similar to Blumberg's sign)

feel pain when hand is removed from pressing RLQ for appendicitis

Murphy’s sign

Palpating RUQ (expected gallbladder) and ask to take a deep breath and if they feel pain - may feel sharp pain with inspiration for cholecystitis (inflammation of gallbladder)

Palpate Liver

Take a deep breath, exhale, then push down on where you expect liver to be (have non-dominant hand posterior to support)

Palpate Spleen

Not normally palpable- place non-dominant hand behind to support rib; take deep breath and with exhale, push down with dominant hand

Percuss Liver

Starting in the midclavicular line at about the 3rd intercostal space, lightly percuss and move down. Percuss inferiorly until dullness denotes the liver's upper border (usually at 5th intercostal space in MCL). Resume percussion from below the umbilicus on the midclavicular line in an area of tympany. Percuss superiorly until dullness indicates the liver's inferior border. Measure span in centimeters

Percuss Spleen

midclavicular, last intercostal space, percuss, ask pt. to take deep breath while continuing to percuss - listen if the sound changes (if so, may indicate enlargement of the spleen, but need to palpate and do further assessment to be sure)