Health Assessment Exam 1: Weeks 1-3
*did not include several slides such as how to talk to the silent patient, crying patient, confused patient,
etc……
WEEK 1 LECTURE:: INTRODUCTION TO ASSESSMENT
INTRODUCTION TO ASSESSMENT
1. Critical Thinking→ information is gleaned from hx and PE
a. Merged w/ clinical knowledge, experience, and the best current evidence
b. Clinical reflection means clinical reasoning
2. Assessment, Judgement, & Evidence
a. Assess information
b. Assign priorities
c. Form clinical opinion
d. Reflect own biases
e. Integrate patient and professional preferences
f. Assess further
3. Problem Identification
a. Anything that will need further evaluation an/or attention
i. New findings, uncertain diagnosis, unusual findings, personal/emotional/social difficulties
b. Beware of “red herrings” → bits of information that are distracting and draw your thinking away
from central issues
c. After a match between both subjective and objective data and a presumed dx…
i. Consider appropriate lab and radiologic studies to confirm dx
ii. Specialty consult may be needed
4. The Ethical Context
a. Ethics does not provide answers
b. Consider…
i. Autonomy, beneficence, nonmaleficence, utilitarianism, fairness and justice, deontological
imperatives
5. Evidence-Based Practice
a. System that incorporates the best available scientific evidence into clinical decision-making, in the
care of the individual patient
b. Balances the strength of the evidence, the risks and benefits of treatment, and diagnostic tests, while
integrating clinical expertise
6. Stages of Behavioral Change
a. Precontemplation
i. Not admitting there is a problem yet
b. Contemplation
i. Admitting that there is a problem but not yet ready or sure of wanting to make a change
c. Preparation
, i. Intending to take action in the immediate future, beginning to take small steps toward
change
7. Stages of Behavioral Change:
a. Action
i. Changing behavior, overt modification in behavior
b. Maintenance
i. Being able to sustain action and working to prevent relapse
c. Termination
i. No temptation/confidence in not returning to old behavior
d. Relapse
i. Shift from action or maintenance to an earlier stage (precontemplation or contemplation)
THE HISTORY AND INTERVIEW PROCESS:
Types of Histories:
1. Complete/Comprehensive History
a. Most often recorded first time you see the patient
b. Provides baseline for future visits
2. Inventory History
a. Touches on major points without complete detail
3. Problem or Focused History
a. For acute problems
4. Interim History
a. Chronicles events since last visit
→ Current meds and allergies should be assessed regardless of history type
The General Survey:
● Apparent State of Health
● Level of consciousness
● Signs of distress (cardiac, respiratory, pain, anxiety, depression)
● Skin color and lesions
● Dress, grooming, hygiene
● Facial expressions
● Body/breath odor
● Posture, gait, motor activity
● Height, weight, BMI, waist circumference
, Vital Signs:
● Heart rate: one minute counting the radial pulse with your fingers, or by listening for the apical pulse with
your stethoscope at the cardiac apex
● Respiratory rate: listen or observe for one minute
● Blood pressure: Manual or automated
○ HTN: Average of 2 readings on 2 separate occasions >140/90
○ Be sure to choose the right size cuff
○ The patient should avoid smoking, caffeine, or exercise for 30 minutes prior to measurement
○ Feet flat on the floor
○ DON’T measure over clothing
○ AC at the level of the heart; support patient’s arm if needed
● Temperature: various ways to measure
● Pain: various assessment techniques
VITAL SIGNS: PEDIATRICS
● Weight
○ Infant scale (most go to about 30-35 pounds)
● Length
○ Under 2, measure supine (can be a difficult measurement to obtain)
● BMI
○ Measure in children older than 2
● Head circumference
○ Measure until 2 years
● Blood pressure
○ Start measuring at age 3, sooner if an issue presents
● Heart rate
○ Can be sensitive to illness, exercise, emotion in pediatrics
● Respiratory rate
○ Also more sensitive to illness, exercise and emotion in pediatrics
○ Most accurate when sleeping
● Temperature
○ Rectal temperature most accurate in infants
PEDIATRICS: THE HEALTH HISTORY/EXAM
● Observe the parent-child interaction during the visit
○ Assess the “goodness of fit” between parents and child
● Observe unstructured play in the exam room
○ Abnormalities in physical, cognitive, and social development or issues with parent–child
relationship
*did not include several slides such as how to talk to the silent patient, crying patient, confused patient,
etc……
WEEK 1 LECTURE:: INTRODUCTION TO ASSESSMENT
INTRODUCTION TO ASSESSMENT
1. Critical Thinking→ information is gleaned from hx and PE
a. Merged w/ clinical knowledge, experience, and the best current evidence
b. Clinical reflection means clinical reasoning
2. Assessment, Judgement, & Evidence
a. Assess information
b. Assign priorities
c. Form clinical opinion
d. Reflect own biases
e. Integrate patient and professional preferences
f. Assess further
3. Problem Identification
a. Anything that will need further evaluation an/or attention
i. New findings, uncertain diagnosis, unusual findings, personal/emotional/social difficulties
b. Beware of “red herrings” → bits of information that are distracting and draw your thinking away
from central issues
c. After a match between both subjective and objective data and a presumed dx…
i. Consider appropriate lab and radiologic studies to confirm dx
ii. Specialty consult may be needed
4. The Ethical Context
a. Ethics does not provide answers
b. Consider…
i. Autonomy, beneficence, nonmaleficence, utilitarianism, fairness and justice, deontological
imperatives
5. Evidence-Based Practice
a. System that incorporates the best available scientific evidence into clinical decision-making, in the
care of the individual patient
b. Balances the strength of the evidence, the risks and benefits of treatment, and diagnostic tests, while
integrating clinical expertise
6. Stages of Behavioral Change
a. Precontemplation
i. Not admitting there is a problem yet
b. Contemplation
i. Admitting that there is a problem but not yet ready or sure of wanting to make a change
c. Preparation
, i. Intending to take action in the immediate future, beginning to take small steps toward
change
7. Stages of Behavioral Change:
a. Action
i. Changing behavior, overt modification in behavior
b. Maintenance
i. Being able to sustain action and working to prevent relapse
c. Termination
i. No temptation/confidence in not returning to old behavior
d. Relapse
i. Shift from action or maintenance to an earlier stage (precontemplation or contemplation)
THE HISTORY AND INTERVIEW PROCESS:
Types of Histories:
1. Complete/Comprehensive History
a. Most often recorded first time you see the patient
b. Provides baseline for future visits
2. Inventory History
a. Touches on major points without complete detail
3. Problem or Focused History
a. For acute problems
4. Interim History
a. Chronicles events since last visit
→ Current meds and allergies should be assessed regardless of history type
The General Survey:
● Apparent State of Health
● Level of consciousness
● Signs of distress (cardiac, respiratory, pain, anxiety, depression)
● Skin color and lesions
● Dress, grooming, hygiene
● Facial expressions
● Body/breath odor
● Posture, gait, motor activity
● Height, weight, BMI, waist circumference
, Vital Signs:
● Heart rate: one minute counting the radial pulse with your fingers, or by listening for the apical pulse with
your stethoscope at the cardiac apex
● Respiratory rate: listen or observe for one minute
● Blood pressure: Manual or automated
○ HTN: Average of 2 readings on 2 separate occasions >140/90
○ Be sure to choose the right size cuff
○ The patient should avoid smoking, caffeine, or exercise for 30 minutes prior to measurement
○ Feet flat on the floor
○ DON’T measure over clothing
○ AC at the level of the heart; support patient’s arm if needed
● Temperature: various ways to measure
● Pain: various assessment techniques
VITAL SIGNS: PEDIATRICS
● Weight
○ Infant scale (most go to about 30-35 pounds)
● Length
○ Under 2, measure supine (can be a difficult measurement to obtain)
● BMI
○ Measure in children older than 2
● Head circumference
○ Measure until 2 years
● Blood pressure
○ Start measuring at age 3, sooner if an issue presents
● Heart rate
○ Can be sensitive to illness, exercise, emotion in pediatrics
● Respiratory rate
○ Also more sensitive to illness, exercise and emotion in pediatrics
○ Most accurate when sleeping
● Temperature
○ Rectal temperature most accurate in infants
PEDIATRICS: THE HEALTH HISTORY/EXAM
● Observe the parent-child interaction during the visit
○ Assess the “goodness of fit” between parents and child
● Observe unstructured play in the exam room
○ Abnormalities in physical, cognitive, and social development or issues with parent–child
relationship
