a brief sponateneous statement in the person's own words that describes the reason for the visit.
Present history or history of present illness
chronological record of the reason for seeking care from the time the symptoms first appear until now. Describe pain as PQRST.
Includes childhood illnesses,previous accidents and injuries,chronic illnesses, hospitalizations, surgeries, obstetric history.
Ask about the age and health or the age and cause of death of blood relatives including parents, grandparents and siblings. Specifically ask for family history of heart disease, hypertension, diabetes, cancer, sickle-cell anemia,arthritis,allergies, obesity, seizure disorder, kidney disease and tuberculosis.
Review of Systems
to double check if any significant data was missed in the present illness section
measures a person's self-care ability in the areas of general physical health or absence of illness.
Physical Examination System : How and what is assessed : Normal Findings : Abnormal Findings
Observation- note physical appearance, body structure,mobility and behavior.
Person is alert, appears his age,even skin tone,height ande weight appears within normal range, normal gait,walks smoothly, appropriate expression, speaks clearly and understandable.
confused, drowsy, cyanotic, jaundiced, immobile, excessively short or tall, tripod position, curled up in fetal position, limited joint of motion.
Use scales,caliper,thermometer,check PR and RR simultaneously
T= 35.8 to 37.3;PR-60-100,RR- 10 to 20,BP= 120/80
measurements outside normal range
Inspect for symmetry and palpate for lumps
presence of lumps
Eye- Confrontation test
Tests visual field. Position self at eye level, 2ft away. Direct person to cover one eye with opaque card and to look straight at you with the other eye. Cover own eye opposite to person's covered eye. Hold pencil or finger as target midline and slowl advance it from periphery in several directions. Tell person to say "now" when he starts seeing the object.
Cover one ear, position head 2ft from uncovered ear, shield lips and whisper a 2 syllable word such as Tuesday, armchair,etc.
The person can hear and repeats word correctly.
Person is unable to hear whispered words.
Ear- Weber Test
Place a vibrating tuning fork midline of the skull.
Person shld hear by bone conduction and it should sound equally loud on both ears.
Ear- Rinne test
Compares air conduction and bone conduction sound. Place the stem of thevibrating tuning fork on the mastoid process and ask him or her to signal when the sound goes away. Quickly invert the fork so the vibrating end is near the ear canal. The person should still hear a sound.
Air Conduction should be 2 times greater than bone conduction.
If bone conduction is longer- conductive hearing loss.
Inspect for patency of nostrils. Inspect nares using speculum attached to otoscope.
patent and clear, no discharges and inflammation.
swollen nasal mucosa- rhinitis
Use penlight and tongue blade to inspect, palpate if necessary. Ask client to say "ah" and note movement of uvula to assess CN X (vagus nerve). Use gloves when inspecting the mouth. Then begin anteriorly down to posterior structures. Check gag reflex to test for CN IX (Glossopharyngeal) and X (Vagus). Test CN XII (Hypoglossal Nerve) by asking the person to stick out the tongue
Person able to perform tests and sticks out tongue steadily.
With damage to CN XII, tongue deviates to the paralyzed side. A fine tremor of the tongue occurs with hyperthyroidism and coarse tremor indicates cerebral palsy and alcoholism.
Inspect for symmetry, range of motion, palpate for lymph nodes, palpate the thyroid gland. Have client sip water while you palpate the thyroid from the back.
no lumps, nodes not enlarged
enlarged lymph nodes indicate infection or lymphoma.
Posterior Chest- Palpating for symmetric expansion
Place warmed hands at the level of T9 or T10. Slide hands medially to pinch up a small fold of skin between thumbs. Ask the person to breath deeply.
Thumbs should move apart symmetrically.
Unequal chest expansion occurs with marked atelectasis or pneumonia.
Posterior Chest - Tactile Fremitus
Use either the palmar ball or the ulnar edge of one hand and touch the person's chest while he repeats the words "ninety-nine" or "blue-moon". Start at the apices and palpate from one side to another.
Symmetrical vibrations (vibrations should feel the same at both sides).
Decreased fremitus- obstruction; Increased fremitus- compression or consolidation of lung tissues.
Posterior chest- palpation
using fingers, gently palpate entire chest wall
smooth, no lumps
Crepitus- coarse crackling sensation palpable at skin surface, indicative of subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissues.
Posterior chest - percussing lung fields
Start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders. Then, percuss in the interspaces making a side-to-side comparison all the way down the lung region. Percuss at 5cm intervals.
Hyperresonance- found when too much air is present as in emphysema or pneumothorax. Dull note- signals abnormal density as in pneumonia, atelectasis or tumor.
Posterior Chest - Auscultating lung sounds
Instruct patient to breath through the mouth deeper than usual and while standing behind the patient, auscultate using the flat diaphragm. Listen from apices at C7 down to the base at T10 and laterally from the axilla down to the seventh or eight rib.
Tracheal- high pitch heard at trachea and larynx, greater in expiration;Bronchovesicular- moderate pitch heard over bronchi where fewer alveoli are located, Vesicular- low soft pitch heard over peripheral lung fields where there are more alveoli.
Decreased or absent breath sounds, adventitious sounds include crackles, wheezes.
Anterior Chest- Inspection
Arrange tangential lighting to accentuate any flicker of movement.
If visible, the apical impulse is located at 4th or 5th intercostal space, midclavicular line.
A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy due to increased workload.
Anterior Chest- Palpating the apical impulse.
Localize apical impulse using one finger pad. Asking the person to exhale and hold and rolling the person midway to the left can aid examiner in locating it.
In a person of normal built, apical impulse is palpable at 4th or 5th intercostal space midclavicular line.
Left ventricular dilatation with volume overload displaces impulse down and left and increases force and duration. Apical impulse not palpable with pulmonary emphysema due to over-riding lungs.
Anterior Chest -Palpating across the precordium.
Using the palmar aspects of four fingers, gently palpate for the apex, the left sternal border and the base searching for any other pulsations.
No other pulsations should occur.
A thrill is a palpable vibration that accompanies loud murmurs.
Anterior Chest -Auscultating heart sounds
Clean the end pieces of the stethoscope with an alcohol swab. Before beginning, alert the person: "Just because I am auscultating a long time doesn't mean that something is wrong." Inch the stethoscope in a z-pattern from the base of the heart, then across and down to the apex.
Rate-60 to 100; S1 loudest at apex and S2 loudest at the base. A splitting of S2 in inspiration may be normal.
A pathologic S3 (ventricullar gallop) occurs with heart failure and volume overload.
Anterior chest- auscultating heart sounds
After auscultating at supine position, change position by rolling the person toward his/her left side. Listen with the bell at the apex for the presence of any diastolic filling sound.
No S3 and S4
S3 and S4 and the murmur of mitral stenosis sometimes may be heard only on the left side.
Cranial Nerve : How assessed : Normal Findings : Abnormal Findings
CN I - Olfactory
Test only when person reports loss of smell. First test patency by occluding one nostril and asking the person to sniff. Then, with person's eyes close, occlude one nostril and present an aromatic substance.
Person should be able to identify familiar smell.
Anosmia- decrease or loss of smell with tobacco smoking, allergic rhinitis and cocaine use.
CN II - Optic Nerve
Test visual acuity and visual fields by confrontation (as stated above); Using the opthalmoscope, examine the ocular fundus to determine color,size and shape of optic disc
50 degrees upward, 90 degrees posteriorly, 70 degrees down and 60 degrees nasally.
Visual field loss; papilledema with high ICP and optic atrophy.
CN III,IV and VI -Oculomotor,Trochlear and Abducens
Assess by cardinal positions of gaze (as stated above);check pupils for PERLA
Ptosis occurs with Myasthenia Gravis, strabismus or limited movement.
CN V- Trigeminal
Motor-Assess the muscles of mastication by palpating the temporal and masseter muscles as the person clenches the teeth. Sensory-test light touch sensation and corneal reflex
Muscles should feel equally strong on both sides.
Decreased strenght;assymetry; pain with clenching of teeth.
CN VII- Facial Nerve
Motor-Note mobility and facial symmetry as the person responds to instructions to smile, frown,close eyes tightly,lift eyebrows,show teeth and puff cheeks. Sensory-test only if necessary. Test sense of taste by applying to the tongue a cotton applicator covered with solution of sugar,salt or lemon juice.
Person able to distinguish test. Symmetrical movements
loss of movement and assymetry with brain lesions
CN VIII Acoustic
see Ear tests above
CN IX and X - Glossopharyngeal and Vagus Nerves
Motor-Depress tongue with tongue blade and note pharyngeal movement as the person says "ah". Touch the posterior pharyngeal wall and note gag reflex.
symmetrical soft palate movement
absence or assymetrical soft palate movement.
CN XI- Spinal Accessory Nerve
Examine the sternomastoid and trapezius muscles for equal size. Check equal strength by asking person to rotate the head forcibly against the resistance applied to the side of the chin.
movements should feel equally strong on both sides.
atrophy, muscle weakness or paralysis.
CN XII - Hypoglossal Nerve
Inspect the tongue by asking person to stick it out at midline. Ask person to say "light,tight,dynamite"
No tremors. Clear and distinct sounds of letters l, t and d.