NURS 5220/ NURS5220 Exam 1 – Advanced Health Assessment and Diagnostic Reasoning Review | UTA (Latest Update) 100% Verified Questions & Answers | Complete Exam Preparation Material

NURS 5220/ NURS5220 Exam 1 – Advanced Health Assessment and Diagnostic Reasoning Review | UTA (Latest Update) 100% Verified Questions & Answers | Complete Exam Preparation Material 2026/2027 | GRADED A+ | 100% VERIFIED Question: In which age group are milia an expected finding? A. Newborns B. Young children C. Adolescents D. Older adults Answer A Question: On palpation of an older individual's skin, you observe "tenting." Which of the following would be most appropriate for you to do in regard to this condition? A. Have the individual further evaluated for dehydration. B. Refer the client for punch biopsy of the skin. C. Inform the individual to be especially vigilant in self-screening for skin cancer. D.Observe the skin carefully for other manifestations of loss of skin integrity. Answer A Question: Skin color is dependent on which of the following cells? A. Carotenocytes B. Melanocytes C. Dermatocytes D. Keratinocytes Answer B Question: Wrinkling of the skin is less marked in individuals who: A. are obese. B. demonstrate premature graying. C. are white. D. have overactive sebaceous and sweat gland activity. Answer A Question: Molding of the infant's head is caused by: A. premature closure of the fontanels. B. shifting and overlapping of the skull bones during birth. C. subperiosteal edema. D. increased cerebrospinal fluid. Answer B Question: In addition to the head, neck, axilla, and inguinal areas, the examiner may also assess lymph nodes: A. on the palmar aspect of the hands. B. in the popliteal region. C. in the patellar region. D. on the dorsum of the foot. Answer B Question: When you ask the patient to clench the teeth and then to smile, which cranial nerve are you testing? A. Trochlear B. Abducens C. Facial D. Vagus Answer C Question: The color of the nasal mucosa should appear: A. deep pink. B. red. C. bluish gray. D. pale pink. Answer A Question: The pneumatic attachment to the otoscope is used to evaluate which characteristic of the tympanic membrane? A.Vibrations B.Mobility C.Tension D.Strength Answer B Question: A tympanic membrane that is retracted is also more: A. concave. B. convex. C. impacted. D. dilated. Answer A Question: To which problem are older individuals more prone? A. Increased sensitivity to tastes B. Hyperactivity of the salivary glands C. Decreased salivation D. Edema of the tongue Answer C Question: During the course of the interview, a patient indicates that he has been given the drug gentamicin (an aminoglycoside antibiotic) for an upper respiratory infection. Based on this information, you would check for which type of problem? A. Dizziness and vertigo B. Recurrent nosebleeds C. Hearing loss D. Oral lesions Answer C Question: A function of cerumen in the ear canal is to provide: A. vibration. B. lubrication. C. sound transmission. D. adhesiveness. Answer B Question: Which of the following situations is an indication for transillumination? A. The patient complains of epistaxis. B. The patient has crepitus with jaw movement. C. The parotid gland is palpable and tender. D. The patient complains of pain over the sinuses with palpation Answer D Question: Which finding is most likely to cause an examiner to suspect a foreign object in the nose of a young child? A. There is a purulent discharge from the child's nose. B. The turbinates appear bluish gray and boggy. C. The child cries when the soft tissue of the nose is palpated. D. Unilateral nasal flaring is present. Answer A Question: In the older adult patient, stature begins to decline at: A. 40 years of age. 50 years of age. 60 years of age. 70 years of age. Question: Present problem Answer Step-by-step evaluation of circumstances Question: Focused history Answer Taken during an acute situation requiring immediate attention Question: Interim history Answer A chronicle of events since last meeting with the patient Question: Chief complaint Answer Brief description of the perceived problem Question: Medical history Answer Previous childhood and adult illness Question: Social history Answer Education, home environment, hobbies Inventory history Answer Touches on major points of concern without detail Systems review Answer Organized physiologic data Family history Pedigree diagram or genogram Complete history A history completed the first time a patient is seen A 4x3cm rough, elevated area of psoriasis is an example of plaque A musical squeaking noise heard b auscultation of the lungs is called wheezing An apical PMI palpated beyond the left fifth intercostal space indicated left ventricular enlargement Behavior approved by the group standards is the norm Blood pressure is a peripheral measurement of cardiovascular function Coarse, dry, brittle hair is associated with which metabolic disorder hypothyroidism Contraction of the ventricles causes closure of the mitral and tricuspid valves If the apical pulse is more vigorous than expected to the chest wall, it is called heave or lift In barrel chest, the ratio of the AP diameter to the transverse is equals 1.0:1.0 or greater Mr. Harris is a 42-year-old patient who is evaluated in the clinic. Currently he is on disability and his diet is poor. You are concerned that he has a vitamin C deficiency. Which of the following foods would increase his vitamin C intake? Raw green vegetables Painful vesicles are associated with herpes zoster Skin turgor checks are performed in order to determine hydration To palpate inguinal nodules, you should have the patient lie supine with the knee slightly flexed When examining a infant's middle ear the practitioner should use one hand to stabilize the otoscope against the head while using the other hand to pull the auricle down Where would the nurse palpate when assessing the submental lymph nodes? Midline behind the tip of the mandible When hearing is being tested what cranial nerve is being tested? VIII Which is a function of Vitamin D? Helps enzymes that aid in calcium absorption Which statement best describes the role of Vitamin E in the human body? Protects cell membranes from oxidation Which statement best describes the chief complaint? A. General health and illness B. The reason the individual is seeking care C. Information to make the diagnosis D. Concerns about confidentiality and trust B A conversation with a parent concerning a 5-year-old child: A. violates the child's need for privacy. B. is inappropriate because the child is able to talk with you. C. provides significant information about family dynamics. D. causes distrust in the child toward the examiner. C J.F. shares with you that he has an uncle and a brother with sickle cell disease. Where would this information best be documented? A. Chief complaint B. Medical history C. Social history D. Family history D A mother runs into the emergency department with her 6-year-old son. She says that her son fell 15 feet from a tree. The child is screaming and has an open fracture of the left forearm. You would conduct a(n): A. complete history. B. focused history. C. problem-oriented history. D. interim history. B Some older adults may have sensory losses that make communication more difficult. Some degree of hearing loss is common in older adults. One action that tends to worsen hearing or communication problems is: A. positioning yourself so the patient is looking at your face. B. speaking clearly and slowly. C. using a high-pitched voice. D. avoiding noisy interviewing rooms. C A health care provider develops a cultural knowledge base to: A. anticipate the patient's adherence to a treatment plan. B. predict behaviors and attitudes. C. understand the behaviors, practices, and problems observed. D. change undesirable behavior or practices to conform to health care practice. C A common mistake made by health care professionals is to: A. acknowledge the practice of folk or herbal remedies. B. adapt health care concepts to meet the needs of individuals of other cultures. C. stereotype individuals based on their color or ethnic group. D. overestimate the ability of individuals from diverse cultures to understand health care concepts. C Cultural beliefs and behaviors that will have an effect on your assessment of the patient include which of the following? A. Diet and nutritional practices. B. The nature of relationships within a family C. Modes of communication: the uses of speech, body language, and space D. All of the above D What part of the hand is best for the examiner to use to palpate a superficial mass detected in the skin? A. Finger pads B. Heel of the hand C. Dorsal surface of the hand D. Ulnar surface of the hand A According to the Centers for Disease Control and Prevention, the health care provider should apply infection control measures to which group of patients? A. Patients with a known infectious disease B. Patients with a possible infectious disease C. Patients who appear ill D. All patients regardless of their infectious status D In which of the following situations is transillumination an appropriate examination technique? A. Assessment of vesicles on the skin B. Detection of fluid within the sinuses C. Measurement of bone density in the skull D. Determination of a mass in the abdomen B Temperature changes are best assessed by: A. the ulnar surface of the hand. B. the dorsal aspect of the hand. C. the tips of the fingers. D. the ventral aspect of the fingers. B During auscultation of a patient's heart, the sounds from the TV are interfering with adequate hearing of the heart sounds. Which of the following options would be best in this situation? A. Ask the patient to turn off/mute the TV for a couple of minutes. B. Turn up the sound on the stethoscope. C. Come back when the TV is off. D. Skip the auscultation examination for this time. A How is a blood pressure reading affected if a wide adult cuff is used on a small child? A. Blood pressure readings will be lower. B. Blood pressure readings will be higher. C. Systolic readings will be falsely high and diastolic falsely low. D. Blood pressure readings will be variable because correct cuff size is a matter of comfort. A Pain has been referred to as the fifth vital sign. Which statement is true of pain and its management? A. Pain is exclusively a physiologic response. B. The patient determines what is an unacceptable pain level. C. Tolerance and addiction to pain medication are universal phenomena. D. There is a single cause of pain for each patient. B In the older adult patient, stature begins to decline at: A. 40 years of age. B. 50 years of age. C. 60 years of age. D. 70 years of age. B Which occurrence marks the completion of skeletal growth? A. Fused epiphyses of long bones B Eighteenth birthday C. Fused epiphyses of all bones D. Fifteenth birthday A A baby's height, until 2 years of age, is measured by: A. the recumbent length. B. stadiometer. C. height weight parameters. D. skinfold thickness. A Which factor accounts for the decline in stature of an older adult? A. Increased trifold skin thickness B. Decreased weight compared with height C. Kyphosis D. Decreased muscle mass C The tool that uses physical and neuromuscular findings to confirm the gestational age of a newborn is: A. the Keating Fetal Assessment. B. the Ballard Clinical Assessment. C. the Winslow Fetal Growth Assessment. D. all of the above. B A history of an individual's food intake is important because it: A. allows estimation of the adequacy of the diet. B. identifies foods from the food pyramid. C. compares the recommended dietary allowances to the US Department of Agriculture food pyramid. D. compares diet and exercise. A A skin lesion that may be associated with neurofibromatosis or pulmonary stenosis is: A. café au lait spots. B. nevus vasculosus. C. port wine limb stain. D. spider angioma. A Which of the following techniques helps the examiner determine whether a palpable skin mass is filled with fluid? A. Using a Wood's lamp B. Biopsy C Transillumination D. Noting the odor of the lesion C Which of the following findings suggests that a patient has a fungal infection of the nail beds? A. The nail bed is wide and thick. B The nail plate has a central depression, causing a spoon appearance. C. Superficial white spots are present in the nail plate. D. The nail plate is yellow and crumbling. D Skin color is dependent on which of the following cells? A. Carotenocytes B. Melanocytes C. Dermatocytes D. Keratinocytes B Wrinkling of the skin is less marked in individuals who: A. are obese. B. demonstrate premature graying. C. are white. D. have overactive sebaceous and sweat gland activity. A On palpation of an older individual's skin, you observe "tenting." Which of the following would be most appropriate for you to do in regard to this condition? A. Have the individual further evaluated for dehydration. B. Refer the client for punch biopsy of the skin. C. Inform the individual to be especially vigilant in self-screening for skin cancer. D. Observe the skin carefully for other manifestations of loss of skin integrity. A Mr. Jones is a 55-year-old gentleman with diabetes. To visualize his macula, the examiner should ask Mr. Jones to: A. blink the eye several times quickly. B. lie in a supine position. C. look directly into the light of the ophthalmoscope. D. direct eye gaze on an object to the left and then to the right. C Which is the correct technique for performing a fundoscopic examination with a traditional ophthalmoscope? Examine the patient's: A. right eye with your right eye, and the left eye with your left eye. B. right eye with your left eye, and the left eye with your right eye. C. right and left eyes with your dominant eye. D. right and left eyes with your nondominant eye. A Which of the following cranial nerves directly connects the eye to the brain? A. Abducens B. Trochlear C. Optic D. Oculomotor C Which finding is most likely to cause an examiner to suspect a foreign object in the nose of a young child? A. There is a purulent discharge from the child's nose. B. The turbinates appear bluish gray and boggy. C. The child cries when the soft tissue of the nose is palpated. D. Unilateral nasal flaring is present. A A function of cerumen in the ear canal is to provide: A. vibration. B. lubrication. C. sound transmission. D. adhesiveness. B To which problem are older individuals more prone? A. Increased sensitivity to tastes B. Hyperactivity of the salivary glands C. Decreased salivation D. Edema of the tongue C A tympanic membrane that is retracted is also more: A. concave. B. convex. C. impacted. D. dilated. A Which type of breath sounds are normally auscultated over most of the lung fields? A. Vesicular B. Bronchovesicular C. Bronchial D. Tubular A Breath sounds normally heard over the trachea are called: A. bronchovesicular. B. amphoric. C. bronchial. D. vesicular C SOAP note SOAP note is both a process and a documentation format The Partnership with the Patient Getting to know your client: Culture Physical characteristics Influence on health and illness Beliefs and behaviors Family relationships Preparing to be an effective health care provider The History and Interviewing process The history and physical exam begin the diagnostic and treatment process The techniques you will learn are orderly but not rigid To prevent misinterpretations and misperceptions, you must make every effort to view the patient's perspective. GOALS Discover information leading to diagnosis and management Provide information about diagnosis Negotiate and share health care management Counsel about disease prevention Autonomy Patient's self-determination Beneficence Do good for the patient Nonmaleficence Do no harm to the patient Utilitarianism Appropriate use of resources for the greater good Fairness and Justice Equitable treatment of all Deontological imperatives Care delivered according to traditions and in cultural contexts Factors that Enhance Communication Establishing a positive patient relationship depends on communication built on: Courtesy Comfort Connection Confirmation Confidentiality Be Professional: Attire & Response Enhancing Patient Responses Establish rapport and trust-Seek connection Open‐Ended Question-Allows patient discretion about the extent of an answer Direct Question-Seeks specific information Leading Question -May limit the information provided to what the patient thinks you want to know If the patient does not understand what you are asking, remember to: Facilitate: Encourage your patient to say more Reflect: Repeat what you have heard. Clarify: Ask "What do you mean?" Empathize: Show understanding and acceptance. Confront: Address disturbing patient behavior. Interpret: Repeat what you have heard to confirm the patient's meaning. Communication TensionsLimit barriers curiosity about you anxiety silence depression crying physical intimacy emotional intimacy anger avoidance financial considerations Setting for the Interview comfort removal of physical barriers good lighting privacy quiet unobtrusive access to clock Taking the history usually begins... your relationship with the patient Structure of the History Identifiers: name, date, time, age, gender, race, occupation, and referral source • Chief concern/complaint (CC) • History of present illness (HPI) • Past medical history (PMH) • Family history (FH) • Personal and social history (PH/ SH) • Review of systems (ROS) Basic Rules for Building the History • Introduce yourself • Address patient properly • Be courteous • Make eye contact • Do not overtire patient • Do not be judgmental • Be flexible Avoid medical jargon • Take notes sparingly • Avoid leading questions • Start with general concerns, then move to specific descriptions. • Clarify responses with where, when, what, how, and why questions. • Verify and summarize what you have heard Building the History • Identify what the patient defines as problems. • Establish patient's reliability. • Consider intentional or unintentional suppression or underreporting of information. • Evaluate patient's words and behaviors. • Adapt to the modifications that age, pregnancy, and physical and emotional handicaps mandate Approaching Sensitive Issues • Ensure privacy. • Be direct and firm. • Do not apologize for broaching the issue. • Do not preach. • Use language that is understandable. • Do not push too hard. Sensitive Issues • Alcohol and drug use • Domestic violence • Spirituality • Sexuality CAGE Questionnaire - Cutting down - Annoyance by criticism - Guilty feeling - Eye‐openers TACE Questionnaire T-How many drinks does it Take to make you feel high? A-Have people Annoyed you by criticizing your drinking? C-Have you felt you ought to Cut down on your drinking? E-Have you ever had an Eye‐opener drink first thing in the morning to steady your nerves or get rid of a hangover? The CRAFFT questions are a means of screening adolescents for substance‐related problems C-Have you ever ridden in a Car driven by someone (You?) who is high on alcohol or drugs? R-Do you use alcohol or take drugs to Relax, feel better about yourself, or fit in? A-Do you ever use alcohol or take drugs while you are Alone? - F-Do you ever Forget things you did while using drugs or alcohol? F-Have a Family member or Friend told you to cut down on drinking or drug use? T-Have you ever gotten into Trouble from using alcohol or taking drugs? Screening vs. Assessment There is a difference between a screening and an assessment interview. The goal of screening is to find out if a problem exists - This is particularly true of CAGE, CRAFFT, and TACE questionnaires. They are effective, but they are only the start, and assessment goes on from there Intimate Partner Violence Both men and women suffer from intimate partner violence (IPV). More women experience IPV They come from every ethnic and socioeconomic group Three questions comprise a brief screening instrument to detect partner violence - Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year? - Do you feel safe in your current relationship? - Is there a partner from a previous relationship who is making you feel unsafe now? Domestic Violence: HITS Verbal abuse is as intense a problem as physical violence. The wording of the question is: "In the last year how often did your partner: - Hurt you physically?" - Insult or talk down to you?" - Threaten you with physical harm?" - Scream or curse at you?" Spirituality Many patients want attention paid to spirituality Faith can be a key factor in the success of a management plan. Some patients may prefer that you not breach the subject. The acronym FICA can be used as an approach FICA Faith, Belief, Meaning What is your spiritual heritage? What writings are important to you? Do these beliefs help you cope with stress? Importance and Influence - How have these beliefs influenced how you handle stress? To what extent? Community - Do you belong to a formal spiritual or religious community? Address/Action in Care - How do your religious beliefs affect your health care decisions? How would you like me to support you in this regard when your health is involved? sexuality The sexual orientation of a patient must be known if appropriate continuity of care is to be offered Trust can be better achieved if questions are "gender neutral." - Tell me about your living situation. - Are you sexually active? In what way? Subjective Data Subjective = States/ Says Subjective = Symptoms The purpose of the subjective interview is to identify PATTERNS Outline of the History Chief complaint (CC) or the reason for seeking care History of present illness or problem (HPI) Past medical history (PMH) Family history (FH) Personal and social history (PH/ SH) Review of systems (ROS) CC: Chief complaint/concern Reason for seeking Care Always in the patients' words—this sets the focus of the visit. (may need to teach staff!) Should only be a couple of sentences. "I am here for a physical exam." "I need my cholesterol checked." "My wife says I forget everything." Ways to elicit CC: • What do you want to work on today? • What is bothering you the most today? Note all significant complaints Seek answer to the question "What underlying problems or symptoms brought you here?" Determine the duration of the current illness by asking "How long has this problem been present?" Or "When did these symptoms begin?" Note age, gender, marital status, occupation, and previous hospital admissions HPI: History of Present Illness/ Problem About 80% of your diagnosis will come from the historical information you collect Establish the problem or the CC HPI = Symptom Analysis Helps differentiate between possible causes Helps in ruling in or ruling out possible causes HPI: Explore the following Chronology of events Health state before present problem First symptoms Exposure to infection or toxic agents Typical attack Illness impact on lifestyle Stability of problem Immediate reason for visit Review of involved systems Medications list Complementary or alternative therapies Chronology review Problem list HPI should include the following: Onset Setting Location Quality Aggravating/ Alleviating factors Associated symptoms HPI‐describes the illness starting with the last time the patient felt well Start open‐ended, then move to more specific questions Some of you are probably excellent at this 7 Variables of a Symptom Analysis Timing Location Quality Quantity/severity Setting Aggravating/alleviating factors Associated factors OLDCARTS, COLDSPA Onset, location, duration, characteristics, aggravating, relieving, treatments, severity LOCATES Location, other associated symptoms, character/quality, alleviating/aggravating, timing, environment/setting, severity Variables of a Symptom Analysis Describes the nature Quality of the symptom Sharp, dull Stabbing Colicky "It feels like something is squeezing in there" Associated factors Anything else that happens with the CC Pertinent positives and negatives a way of sorting your findings into evidence supporting your diagnosis Supports or does not support your diagnosis PMH: Past Medical History Explore the following • Past medications • Allergies (drugs, environment, food) • Past transfusions • Recent screening tests • Emotional status • General health • Childhood illnesses • Major adult illnesses • Immunizations • Surgery • Serious injuries and resulting disability • Functional ability limitations Current Health Data • Medications‐prescription, OTC, herbal, vitamins, supplements. Reason for taking. • Allergies‐foods, meds, environmental. Include type of reaction to each one. Example: codeine/nausea. • Date, results of last physical. • Screening tests, results. Includes mmg, pap, c‐scope, PSA, lipids, etc. • Immunizations - Name and date (or age) - please don't say UTD! LMP LNMP BCM/MOC‐document type and typical use. "I use condoms for birth control" "Every time." "Well, every time I have one." Please ask your male and female patients about condom/protection use. Past Medical History • Childhood illnesses‐ask about pertussis, varicella, measles, mumps, rubella, polio. • Adult illnesses‐the common ones‐cancers, CAD, HTN, thyroid, diabetes. Plus, always ask about h/o STI. • Traumas, injuries, disabilities. • Hospitalizations and blood/blood product transfusion. Common in premature infants, often forgotten by parents. • Surgeries‐ Circumcision/ C‐ Sections/ BTL/ Vasectomy are commonly forgotten Past Medical History Obstetric/ Gynecologic Menarche Menopause History of contraceptive or hormone use. Infections, procedures, devices, etc. OB history abbreviations GPTPAL GPTPAL Gravida‐how many pregnancies? Term‐how many full-term pregnancies? Preterm‐how many pre‐term pregnancies? Abortions‐spontaneous or induced Living children Complications Sexual history You will make your client uncomfortable if you are not comfortable with the questions Privacy‐ Confidentiality You may need to explain the reason for asking personal questions Give permission not to answer questions they don't want to Audiotape advice! Current sexual relationship/s BCM/ MOC Number of (lifetime)current and previous partners Sexual debut (onset of coitus) Specifics - Gender preference (Do you prefer sex with males, females, both or neither?) - Oral, Anal, Vaginal Psychiatric History Dates Diagnoses Treatments, including herbal Results FH: Family History Explore the following Blood relatives with illness similar to the patient's illness Blood relatives with history of major disease Determine if any cancers have been multiple, bilateral, occurring more than once in the family, and occurring at a young age (less than 50 years) Note the age and outcome of any illness. Note the ethnic and racial background of the family Note the age and health of the patient's spouse/partner or the child's parents. Genogram (pedigree diagram) helps illustrate the family members with a disorder - There should be at least three generations for the pedigree Family History Medical History Purpose: to elicit patterns of genetic or familial risk Genogram or narrative (we will ask for both in this course, please) • Age, health of living family members Age and cause of death of deceased members Parents, grandparents, children, siblings May go back further in certain cases, such as reproductive health, known genetic problems Personal and Social History • Personal status • Habits • Sexual history • Home conditions • Occupation • Environment • Military record • Religious preference • Access to care • Education • Stressors • Hobbies/leisure • Religious/spiritual beliefs • Cultural background and health beliefs • Financial situation (a biggie right now!) • Safety in home • Housing • Housemates • Pets • Weapons • Smoke detectors • Remember to extend this to neighborhoods— like ability to get groceries, safety to exercise • Working conditions • Exposures to toxins • Job satisfaction • Protective devices • Any safety concerns • Long hours • Alcohol • Drugs • Caffeine • Tobacco products, also secondhand smoke • Seatbelts • Helmets • Sunblock • Multiple questionnaires also are available to help screen for health risks Personal and Social History ADLs This is done to get an idea of your patient's typical day. This is most useful with: • Elderly • Psychiatric patients • Differently abled patients • Children/adolescents Personal and Social History Environmental • Travel • Camping • Also, some housing conditions Ex: house built before 1978 is at risk for: lead ROS: Review of systems Purpose is to take an inventory of the body systems looking for s/s that the pt. May not recognize as important Example: pregnant patient with swollen feet ROS explores • General constitutional symptoms • Skin, hair, and nails • Head and neck • Lymph nodes • Chest and lungs • Breasts • Heart and blood vessels • Peripheral vascular • Hematologic • Gastrointestinal • Diet Endocrine - Female - Male • Genitourinary • Musculoskeletal • Neurological • Psychiatric • Concluding questions Comprehensive ROS • Involves questions about each of the 17 body systems • Many times, this is done by checklist, not by provider • Key questions for each system. • Start system with "Are you having any problems with your ‐‐‐‐‐‐‐‐‐‐‐?" Then move to specific questions. types of histories Complete History‐ New Client on first visit Inventory History‐ Major points Problem or Focused History‐ Problem Episodic or Interval visit Interim History‐ on follow up visits Objective Data Examination Techniques and Equipment Objective = Observe Examination Techniques and Equipment Physical Examination Prepare: - Yourself - Client - Environment - Equipment Patient Privacy Disrobe, or uncover only the patient's areas you are immediately examining, and then cover and move to the next exam area Physical Exam- 4 techniques Inspection (looking) Percussion(tapping) Palpation (touching) - Light - Deep Auscultation (listening) Examination Techniques and Equipment Patient Positioning Seated‐ used for most assessment with access to anterior and posterior upper body parts Supine‐ used for most assessment with access to anterior body parts of upper and lower body Prone‐ used for most assessment with access to posterior body parts of upper and lower body; used for musculoskeletal assessment Dorsal Recumbent‐ used for assessment with access to genital and rectal areas Lateral Recumbent‐ used for auscultation of the heart and palpation of the spleen Lithotomy‐ used for pelvic examination Sims‐ used for examination of rectum Examination Techniques and Equipment Order of Physical Examination • Inspection • Palpation • Percussion • Auscultation EXCEPT Abdomen Abdomen order of examination Inspection Auscultation Percuss Palpation inspection observation used for data collection using eyes and nose can use extra lighting palpation Sense of Touch used for data collection Palmer surface of fingers and finger pads are more sensitive to determine position, texture, size, consistency, masses, fluid and crepitus. Ulnar surface of and finger are sensitive to distinguish vibration. Dorsal surface of the hand is best for estimating temperature Light, Deep touch is therapeutic respect boundaries and ask for permission Percussion Sense of touch to produce vibration and sound waves Sound waves are heard as percussion tones or resonance Percussion hammer and Tuning Fork Depth of underlying tissue determines the percussion tones: Tympany Hyperresonance Resonance Dullness Flatness Percussion tones • Tympany‐ gastric bubble • Hyperresonance‐ lungs with emphysema • Resonance‐ healthy lungs • Dullness‐ liver • Flatness‐ muscle • Direct (sinus) • Indirect or mediate (percussion striking own finger) • Blunt (CVA tenderness) • Scratch test Auscultation • Sense of hearing • Stethoscope on bare skin (no fabric) - High pitch sounds (diaphragm) - Low pitch sounds (bell) • Quiet environment • Listen to characteristics of the sound - Intensity - Duration - Pitch - Quality SOAP and Diagnostic Reasoning • CDM involves taking ALL of the possibilities that fit the chief complaint—this is called differential diagnosis. • You will discard the ones that don't fit—this is called "ruling out." • Ruling out is just as important as ruling in • You will use your physical examination, lab tests and imaging to get further information. Diagnostic Reasoning Clinical Decision Making • Differential diagnosis is a PROCESS • Involves taking all the possible explanations for a problem • Discarding the ones that don't fit • Keeping the ones that do fit the patterns • You may develop THE diagnosis—because it is obvious — "GSW to the shoulder" • OR you may have a list of possibilities— "this is what's left in my differential" • AND you may have Rule Out (R/O)s—things that need more work Diagnostic Reasoning Assessment/ Diagnosis • May be a symptom • May be a "working diagnosis" —which means you will start treatment • Rule outs • Health maintenance needs • Risk factors Don't Rush to the Plan More to follow in Management Courses • Med orders • Fluids • Education • Imaging • Lab • Consults • Include tests, therapeutics, education, referrals, • Follow up, and health maintenance Rationale • Rationale is a summary of supporting data for your diagnosis • Some settings do not routinely add this to the chart • You are required to do this for school papers • "Presence of atopic dermatitis and allergic rhinitis suggest that cough is asthma" What is a CPT code? Used to describe evaluation and management services done by providers What is an ICD10 code? Used to describe signs, symptoms, diagnoses, conditions, injuries. Diagnostic Reasoning Step 1 • Create a list of all the possibilities • These possibilities you entertain are differential diagnosis Pathognomonic: means a finding that is so characteristic of a disease that is leads you to a diagnosis in diagnostic reasoning asking questions use your 7 variables of a symptom to narrow list Assign a probability • Cluster and Trend • How likely is this? • Time of year? • Other family members? • Previous symptom? Order Diagnostic Tests • Need to know what the validity of the test is - Specificity - Sensitivity • Cost • Don't order a test if you don't know what to do with it! subjective content Information that comes from opinion, perceptions, or experiences the patient reports Information gathered from the patient telling you something that you did not measure or evaluate building a history Building" a history rather than "taking" one because you and your patient are involved in a joint effort Context of that relationship in emotional, physical, and ethical terms Verbal and nonverbal behavior that you may adapt to your individual comfort and style Approaches to the structure of a history with adaptations suggested for age, gender, and disability History begins with developing a relationship The first meeting with the patient sets the tone for a successful partnership You will be open, flexible, and eager to deal with questions and explanations You will explain the boundaries of your practice and the degree of your availability in any situation Trust evolves from honesty and candor Objectives to developing a patient relationship Primary objectives: To discover the details about a patient's concern To explore expectations for the encounter To display genuine interest, curiosity, and partnership To prevent misinterpretations and misperceptions, you must make every effort to sense the world of the patient as that patient sees it Patient centered care Defined by the Institute of Medicine as: "respecting and responding to patients' wants, needs and preferences, so that they can make choices in their care that best fit their individual circumstances" Your own beliefs, attitudes, and values cannot be discarded, but you do have to discipline them Effective communication Establishing a positive patient relationship depends on communication built on: Courtesy Comfort Connection Confirmation Confidentiality Enhancing patient responses Open-ended question Allows patient discretion about the extent of an answer Direct question Seeks specific information Leading question May limit the information provided to what the patient thinks you want to know Communication Pearls If the patient does not understand what you are asking, remember to: Facilitate: Encourage your patient to say more. Reflect: Repeat what you have heard. Clarify: Ask "What do you mean?" Empathize: Show understanding and acceptance. Confront: Address disturbing patient behavior. Interpret: Repeat what you have heard to confirm the patient's meaning. Barriers to communication Curiosity about you Anxiety Silence Depression Crying Physical intimacy Emotional intimacy Seduction Anger Avoidance Financial considerations Patient History A collection of information about a person's health Identify those matters the patient defines as problems. Establish a sense of the patient's reliability. Consider the potential for intentional or unintentional suppression or underreporting of information. Remain in a constant state of subjective evaluation of the patient's words and behaviors. Adapt to the modifications that age, pregnancy, and physical and emotional disabilities mandate Setting for the interview Comfort for all involved Removal of physical barriers Good lighting Privacy Relative quiet Unobtrusive access to clock Structure of a history The identifiers: name, date, time, age, gender, race, occupation, and referral source Chief concern History of present illness (HPI) Past medical history (PMH) Family history (FH) Personal and social history (SH) Review of systems (ROS) Foundation of your building Introduce yourself Address patient properly Be courteous Make eye contact Do not overtire patient Do not be judgmental Be flexible Sensitive subjects Ensure privacy Be direct and firm Do not apologize for broaching the issue Do not preach Use language that is understandable Do not push too hard Be comfortable Alcohol and drug use Intimate partner violence Spirituality Sexuality CAGE The CAGE questionnaire was developed in 1984 by Dr. John Ewing, and it includes four interview questions designed to help diagnose alcoholism. The acronym "CAGE" helps practitioners quickly recall the main concepts of the four questions (Cutting down, Annoyance by criticism, Guilty feeling, Eye-openers). Probing questions may be asked as follow-up questions to the CAGE questionnaire TACE T-How many drinks does it Take to make you feel high? A-Have people Annoyed you by criticizing your drinking? C-Have you felt you ought to Cut down on your drinking? E-Have you ever had an Eye-opener drink first thing in the morning to steady your nerves or get rid of a hangover? CRAFFT questionnaire developed in 2002 as a screening tool for alcohol and substance abuse in adolescents. The CRAFFT acronym helps practitioners remember the main concepts of the six questions: Car, Relax, Alone, Forget, Friends, Trouble. Screening vs Assessment There is a difference between a screening and an assessment interview The goal of screening is to find out if a problem exists This is particularly true of CAGE, CRAFFT, and TACE questionnaires They are effective, but they are only the start, and assessment goes on from there Intimate partner violence Intimate partner violence (IPV): Range of abusive behaviors perpetrated by someone who is or was involved in an intimate relationship with the victim It affects primarily women, children, and the dependent elderly as victims and, in lesser frequency, men There is significant overlap between IPV and child abuse so when IPV is detected, child abuse should be considered Screening intimate partner violence Three questions comprise a brief screening instrument to detect partner violence: Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year? Do you feel safe in your current relationship? Is there a partner from a previous relationship who is making you feel unsafe now? Intimate partner HITS The wording of the question is: In the last year how often did your partner: Hurt you physically? Insult or talk down to you? Threaten you with physical harm? Scream or curse at you? spirituality Many patients want attention paid to spirituality. Faith can be a key factor in the success of a management plan. Some patients may prefer that you not broach the subject. The acronym FICA can be used as an approach. Spirituality fica Faith, Belief, Meaning: What is your spiritual heritage? What writings are important to you? Do these beliefs help you cope with stress? Importance and Influence: How have these beliefs influenced how you handle stress? To what extent? Community: Do you belong to a formal spiritual or religious community? Address/Action in Care: How do your religious beliefs affect your health care decisions? How would you like me to support you in this regard when your health is involved? sexuality The sexual orientation of a patient must be known if appropriate continuity of care is to be offered - Can not be assumed Trust can be better achieved if questions are "gender neutral" Tell me about your living situation. Are you sexually active? In what way? Outline of a history Chief concern (CC) or the reason for seeking care History of present illness or problem (HPI) Past medical history (PMH) Family history (FH) Personal and social history (PSH) Review of systems (ROS) Chief Concern (CC) In the patient words Note all significant concerns. Seek answer to the question "What underlying problems or symptoms brought you here?" Determine the duration of the current illness by asking "How long has this problem been present?" or "When did these symptoms begin?" Note age, gender, marital status, occupation, and previous hospital admissions History of Present Illness: Explore the following Chronology of events Health state before present problem First symptoms Symptom analysis Typical attack Exposure to infection or toxic agents Illness impact on lifestyle Immediate reason for visit Review of involved systems Medications list Complementary or alternative therapies Chronology review Past medications Allergies (drugs, environment, food) Past transfusions Recent screening tests Emotional status General health Childhood illnesses Major adult illnesses Immunizations Surgery Serious injuries and resulting disability Functional ability limitations Family History Blood relatives with illness similar to the patient's illness Blood relatives with history of major disease Determine if any cancers have been multiple, bilateral, occurring more than once in the family, and occurring at a young age (less than 50 years) Note the age and outcome of any illness Note the ethnic and racial background of the family Note the age and health of the patient's spouse/partner or the child's parents A pedigree diagram helps illustrate the family members with a disorder There should be at least three generations for the pedigree Personal and Social History: Explore the following Personal status Habits Self care Sexual history Home conditions Occupation Environment Military record Religious preference Access to care ROS: General Constitutional Symptoms Fever Chills Malaise Fatigability Night sweats Sleep patterns Weight: Average Preferred Present Change ROS: Skin, Hair, and Nails Rash, eruption, itching Pigmentation or texture change Excessive sweating Abnormal nail or hair growth ROS: Head and Neck Headaches Dizziness Syncope Head injuries Loss of consciousness ROS : Eyes Acuity Blurring Diplopia Photophobia Pain Vision changes Glaucoma Eye medications Trauma ROS: Ears Hearing loss Pain Discharge Tinnitus Vertigo ROS: Nose Sense of smell Colds Obstruction Epistaxis Postnasal discharge Sinus pain ROS: Throat & Mouth Hoarseness or change in voice Sore throats Bleeding gums Tooth abscesses, extractions Soreness or ulcers of tongue/mucosa Taste changes ROS: Lymph Nodes Enlargement Tenderness Suppuration (infection) ROS: Chest & Lung Pain Dyspnea Cyanosis Wheezing Cough Sputum Hemoptysis Night sweats Exposure to tuberculosis Last chest radiograph ROS: Breast Development Pain Tenderness Discharge Lumps Galactorrhea Mammograms Screening Diagnostic Self-awareness Self-examination ROS: Heart Chest pain Palpitations Dyspnea Orthopnea Edema Claudication Hypertension Previous myocardial infarction Exercise tolerance Date of last electrocardiogram Other cardiac tests ROS: Peripheral Vascular Claudication Frequency Severity Tendency to bruise or bleed Thromboses Thrombophlebitis ROS: Hematologic Anemia Blood cell abnormalities Past transfusions ROS: Gastrointestinal Appetite Digestion Food intolerances Dysphagia Heartburn Nausea/vomiting Hematemesis Regularity of bowels Constipation Diarrhea Change in stools Hemorrhoids Jaundice Previous imaging studies ROS: Nutrition Appetite Likes and dislikes Diet restrictions, cultural constraints Vitamins and other supplements Caffeine Dietary recall ROS: Endocrine Thyroid enlargement or tenderness Heat/cold intolerance Weight change Diabetes Polydipsia Polyuria Changes in facial or body hair Increased hat or glove size Skin striae ROS: Endocrine Female: Menses Discharge, itching Last Pap smear Libido, intercourse Birth control Infertility, pregnancy Menopause Male: Puberty onset Erections Emissions Testicular pain Libido Infertility ROS: genitourinary GU Sexually transmitted infections Dysuria Pain Urgency Frequency Nocturia Hematuria Polyuria Hesitancy Dribbling Loss in force of stream Passage of stone Edema of face Stress incontinence Hernias ROS: Musculoskeletal MSK Joint stiffness, pain Restriction of motion Swelling, redness, heat Bony deformity Ros: neuro Syncope Seizures Weakness or paralysis Abnormalities of sensation or coordination Tremors Loss of memory Ros: psychiatric/mental health Depression Mood changes Difficulty concentrating Nervousness Tension Suicidal thoughts Irritability Sleep disturbances ROS: Male /Female Females: Menses Menarche Cycle LMP Pregnancy Males: Puberty onset difficulty with erections emissions testicular pain Libido infertility Concluding questions Is there anything else that you think would be important for me to know? What problem concerns you most? What do you think is the matter with you? What worries you the most about how you are feeling? children Pay attention to them (place equal emphasis on the child and on the accompanying adult) Play with them Be sensitive to their needs Observe clues about family dynamics Explore: Mother's gestational history, pregnancy, and birth Child's neonatal period, feeding, and developmental milestones Child's school adjustment, habits, and home conditions Adolescents Respect need for confidentiality Respect impending adult status Do not force conversation Establish an alliance Be flexible in approach Factors impacting history taking Self-esteem, acceptance by peers, tension with parents Cover issues of special concern (Hint: Use mnemonic HEEADSSS or PACES to zero in on issues) HEEADSSS for adolescents Home environment Education Eating Activities, affect, ambitions, anger Drugs Sexuality Suicide/depression Safety PACES for adolescents Parents, peers Accidents, alcohol/drugs Cigarettes Emotional issues School, sexuality Pregnant Women View health needs of mother and fetus Explore effects of pregnancy on health status Use interview as time for teaching health care practices Explore: Current pregnancy and obstetric history Exposure to environmental/occupational hazards Family genetic conditions/congenital abnormalities Personal and social issues of pregnancy and parenting Reproductive, cardiovascular, endocrine, respiratory system focus Risk factors that threaten mother and fetus Older Adults Watch for age-related changes that may impede interview: Sensory loss, visual impairment, cognitive impairment, or memory loss Draw on person's cumulative lifetime experience, wisdom, and perspective Explore: Multiple overlapping health problems Chronic symptoms Complete drug assessment Assessment of functional capacity Patients with Disabilities Adapt interview approach to fit needs Involve the patient to the limit of emotional, mental, and physical abilities Family members are often available to make the patient more comfortable and provide further information Types of histories A "complete" history is not always necessary. You may know the patient well and be considering the same problem over time. Adjust your approach to the needs at the moment Complete history Most often recorded the first time you see the patient Inventory history Related to but does not replace the complete history Touches on major points without complete detail Entire history will be completed in more than one session Problem (or focused) history Taken when a problem is acute so that only the need of the moment is given full attention Interim history Designed to chronicle events that have occurred since your last meeting with the patient Substance determined by nature of problem and need of the moment Should always be complemented by the patient's previous medical record Nutrition Assessment From the history and physical examination, assess the patient's nutritional status, including the following: Recent growth weight loss, or weight gain Chronic illnesses affecting nutritional status or intake Medication and supplement use Nutrition screen Assessment of nutrient intake Clinical signs or symptoms of nutrient or energy deficiency Laboratory values Obtain the following anthropometric measurements and compare them to standardized tables: Standing height Weight Calculate body mass index Waist circumference Calculate waist-hip ratio Triceps skinfold (TSF) thickness and mid-upper arm circumference (MAMC) measurements; calculate midarmmuscle circumference/midarm muscle area (MAMA) Water Most vital nutrient; adult body is 55% to 65% water An individual can exist without food for several weeks, but without water, an individual would last only a few days. Approximately 2 to 2½ liters of water are lost daily, which are replaced by: Fluids taken in Water contained in solid foods eaten Water produced in the body as a result of oxidative processes HPI: weight loss Total weight lost, compared with usual weight Time period Desired weight loss Eating habits Undesired weight loss• Associated symptoms Preoccupation with body weight or shape Medications: Chemotherapy, diuretics, insulin, fluoxetine, diet pills, laxatives, hypoglycemics, herbal supplements HPI: weight gain total weight gained Time period, sudden or gradual, desired or undesired, possibility of pregnancy Change in lifestyle• Change in social aspects of eating, more meals eaten out of the home, change in lifestyle, activity, and stress levels Medications: Steroids, oral contraceptives, antidepressants, insulin Anthropometrics Procedures for accurately measuring: Height Weight Triceps skinfold **Mid Arm - skeletal mass Table of norms for relevant age and gender groups These measurements are useful in assessing patients' nutritional status and risk for disease. Body mass index (BMI) healthy 18.5-24.9 Formula used to assess nutritional status and total body fat Waist circumference Large waist circumference often associated with increased risk for type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease Monitoring over time may aid in predicting disease risk for cardiovascular and obesity-related diseases. IBW- Desirable Body Weight Women: 100 pounds for first 5 feet; plus 5 lbs for each inch thereafter Men: 106 pounds for first 5 feet; plus 6 lbs for each inch thereafter Add 10% for large frame Subtract 10% for small frame BMI-Body Mass Index Using Kilograms and centimeters: Weight (in Kg) ÷ Height (meters} 2 Using Pounds [Weight ( in pounds) × Height (inches) 2 ] x 703 Waist-to-hip circumference ratio Not as helpful as the body mass index in assessing total body fat An excess proportion of trunk and abdominal fat (e.g., apple-shaped body) has a higher risk association with diabetes mellitus, dyslipidemia, metabolic syndrome, stroke, and ischemic heart disease than does a larger proportion of gluteal fat (e.g., pear-shaped body). Triceps skinfold thickness Approximately 50% of the body fat is present in the subcutaneous tissue layers Correlation exists between the triceps skinfold thickness and the body's fat content Mid-upper arm circumference (MAMC) Estimate of muscle mass and available fat and protein stores Midarm muscle circumference/midarm muscle area (MAMA) Sensitive index of body protein reserves best indicator for skeletal mass Body temperature is regulated by _____________ hypothalamus Pulse measurement in infants and children apical pulse OLDCARTS mnemonic obtained with HPI - onset, location, duration, character, aggravating factors, relieving factors, temporal factors, and severity of symptoms Normal temperature range 97.2 to 99.9 Routine BPs start at age ____ 3 Fifth vital sign pain