Adult Assessment

Question 1

What is the first step in taking a patients history?

Answer 1

Obtain the patients chief complaint in their own words.

Question 2

Once you determine the chief complaint what is the next step in the history?

Answer 2

HPI: Try to present a clear account of the patients chief complaint including what treatments have been tried, what worked and what didn’t?

Question 3

What acronym helps you remember the HPI?

Answer 3

OLD CART

Question 4

“O”

Answer 4

Onset: where and when

Question 5

“L”

Answer 5

Location: where is the location of the symptoms?

Question 6

“D”

Answer 6

Duration: how long has this been going on, do the symptoms come and go?

Question 7

“C”

Answer 7

Characteristics: describe the symptoms more

Question 8

“A”

Answer 8

Any aggravating factors: does anything make the symptoms worse?

Question 9

“R”

Answer 9

Relieving factors: does anything make it better?

Question 10

“T”

Answer 10

Treatment: what treatments have been tried?

Question 11

Once you have completed the HPI, what is the next step in the history?

Answer 11

Past Medical History (PMH)

Question 12

What follows past medical history?

Answer 12

Past surgical history

Question 13

What follows past surgical history?

Answer 13

Family Medical history

Question 14

What follows Family Medical history?

Answer 14

Lifestyle: Diet, exercise, sleep, tobacco/alcohol/illicit substances, Employment status, living arrangements, seatbelt use, religion

Question 15

What follows lifestyle?

Answer 15

Medications: OTC, inhalers, eye drops, herbal supplements, vitamins, home remedies/cultural treatments.

Question 16

What follows medications?

Answer 16

Allergies: Allergen and reaction

Question 17

What follows allergies?

Answer 17

Immunizations: Influenza, pneumococcal, shingles, TB

Question 18

What follows immunizations?

Answer 18

Review of systems

Question 19

General ROS

Answer 19

Fever/chills, fatigue, unexplained weight changes, sleep difficulties, diaphoresis, night sweats

Question 20

Eyes ROS

Answer 20

Blurred vision, double vision, eye pain, discharge/increased tearing, deviation

Question 21

Nose ROS

Answer 21

Nose bleeds, stuffiness/congestion, nasal discharge, sinus pain

Question 22

Mouth ROS

Answer 22

Lesions/ulcers, pain, tooth loss/cavities, altered taste

Question 23

Throat ROS

Answer 23

Difficulty swallowing, sore throat, voice changes/loss, hoarseness, >2 head colds/year

Question 24

Respiratory ROS

Answer 24

SOB, cough, wheezing, paroxysmal nocturnal dyspnea, dyspnea on exertion, hemoptysis, orthopnea

Question 25

Breast ROS

Answer 25

Changes in skin texture, pain, dimpling, masses/changes in consistency

Question 26

Cardiac ROS

Answer 26

Chest pain, murmurs, palpitations, elevated BP, irregular heart beat

Question 27

Circulatory ROS

Answer 27

Cool extremities, varicose veins, thrombosis, claudication, peripheral edema

Question 28

GI ROS

Answer 28

Dysphagia, heartburn, bloating, eructation, changes in bowel habits, diarrhea, vomiting, constipation, bloody stools

Question 29

Urinary ROS

Answer 29

Frequency, dysuria, hematuria, hesitancy, flank pain, urinary urgency, incontinence

Question 30

Reproductive female ROS

Answer 30

LMP, menopause, irregular bleeding, vaginal discharge, painful intercourse, contraception, partners (gender/#), STD’s

Question 31

Reproductive Male ROS

Answer 31

Testicular pain/lesions, erectile dysfunction, STD’s, penile discharge, hematospermia, partners (gender/#)

Question 32

Musculoskeletal ROS

Answer 32

Joint stiffness, swelling, redness, bone deformity, back/neck pain, weakness

Question 33

Neuro ROS

Answer 33

Dizziness, headache, localized/general weakness, numbness, memory changes/loss, parasthesias, speech changes, gait changes

Question 34

Skin ROS

Answer 34

Changes in pigmentation, changes in moles, new moles, itching, rashes, changes in skin texture, hair texture, changes in nails

Question 35

Mental/emotional ROS

Answer 35

Depression, anxiety, suicidal ideation, difficulty concentrating, stressors, memory loss, hallucinations

Question 36

Heme/endo ROS

Answer 36

Enlarged lymph nodes, anemia, syncope, bruising easily, clotting disorders, polydipsia, polyphagia, heat/cold intolerance

Question 37

General Appearance-physical assessment

Answer 37

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.

Question 38

Vital signs

Answer 38

BP, pulse, temp, respirations, weight, height, BMI

Check postural changes, lying, sitting, standing.

Question 39

How do you check postural changes (orthostatic vitals)?

Answer 39

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)

Question 40

What does low diastolic BP indicate?

Answer 40

<65 mmHg implies decreased peripheral resistance or aortic valve regurgitation (which is significant, even if the heart sounds are not loud)

Question 41

Inspect skin PHYSICAL

Answer 41

Fingernails for clubbing, suspicious or unusual lesions

Question 42

Head PHYSICAL

Answer 42

Inspect the face and head, palate the scalp, temporal area for pulsation and mass ether muscle (have patient clench teeth)