Laboratory Manual
,Preface
The purpose of this Laboratory Manual is to provide structure for students as they practice with classmates acting as
patients to obtain health histories and perform physical examinations.
• The History contains questions about the patient’s Present health state, Past health history, Family history, Personal
and psychosocial history, and Review of Systems with space to document findings. In addition to learning how to
obtain a health history, students learn medical terminology, such as documenting “edema” when patients report
“swelling.”
A table is provided at the end of Chapter 2 to help students learn this terminology. Also, the Review of Systems in
chapters containing a health history uses lay terminology followed by medical terminology in parentheses to help
students learn these terms.
• The Examination section in Chapters 6–17, and 19–22 provides techniques performed in the left column with
space for documenting findings in the right column. Techniques for Special Circumstances have been integrated
within the Routine Techniques. Each examination technique is numbered to facilitate discussion of the skills by
number rather than naming the entire skill. These skills are written to direct the student; thus, the verbs are second
person with an implied “you,” e.g., (You) PERFORM hand hygiene.
• The Clinical Judgment that follows the history and examination sections uses the first two layers of the Clinical
Judgment Measurement Model to help students analyze data. These include: 1) Recognize cues for this patient.
Identify relevant findings from the history and examination and 2) Analyze cues. Organize and link the recognized
cues to the patient’s clinical presentation.
• A Performance Check List for examination skills has been added following each examination section in Chapters
7–17 and 22 as a structure to evaluate students. There are four descriptors of performance: Correct (C), Incomplete
(Inc), Incorrect (I), and Not performed (NP). Skills in the Check List are numbered the same as those in the exam-
ination section. These skills are written to direct the evaluator; thus, the verbs are present tense, third person with
an implied “he or she”, e.g., (He/She) PERFORMS hand hygiene.
• Following the Skills Performance Check List is an Implementation checklist that allows an appraisal of the student’s
implementation of the examination including assembly and use of equipment, the organization of the examination,
the confidence demonstrated by the student, and the student’s interaction with the “patient.” These skills are written
to direct the evaluator who assesses the implementation of the examination; thus, the verbs are past tense, third
person with an implied “he or she”, e.g., (He/She) Assembled needed equipment.
• At the end of the Check List there is space to tally the number from each category of descriptors in each of the
categories in Examination and Implementation.
• There are no laboratory activities for Chapters 1, 18, 23, and 24.
iii
,
,Contents
Chapter 2 Obtaining a Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 3 Techniques and Equipment for Physical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Chapter 4 General Inspection and Measurement of Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Chapter 5 Cultural Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Chapter 6 Pain Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Chapter 7 Mental Health Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Chapter 8 Nutritional Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Chapter 9 Skin, Hair, and Nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Chapter 10 Head, Eyes, Ears, Nose, and Throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Chapter 11 Lungs and Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Chapter 12 Heart and Peripheral Vascular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Chapter 13 Abdomen and Gastrointestinal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Chapter 14 Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Chapter 15 Neurologic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Chapter 16 Breasts and Axillae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Chapter 17 Reproductive System and the Perineum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Chapter 19 Assessment of the Infant, Child, and Adolescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Chapter 20 Assessment of the Pregnant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chapter 21 Assessment of the Older Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Chapter 22 Conducting a Head-to-Toe Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
v
,Student Name ____________________________________________________________ Date _________________________
CHAPTER 2 Obtaining a Health History
With your lab partner assuming the role of a patient, conduct a comprehensive history. Your “student patient” may role-play
a person with particular related symptoms and history.
HISTORY
BIOGRAPHIC DATA
Date Name Preferred name Sex Gender Identity
Male Male
Female Female
Both
Neither
Date of Age Race/Ethnicity Religion Language(s)
birth
Marital status Occupation
S M D W
REASON FOR SEEKING CARE (Presenting problem)
HISTORY OF PRESENT ILLNESS
Symptom Analysis of Presenting Problem (Onset, Location, Duration, Characteristics, Aggravating factors, Related
symptoms, Treatment, Severity)
PRESENT HEALTH STATUS
• Describe your current health conditions.
ο How long have you had these conditions?
ο How have these health conditions affected your daily activities?
Copyright © 2022 Elsevier, Inc. All Rights Reserved. 1
,2 Chapter 2 Obtaining a Health History
• What medications or supplements do you take? (Include prescription, over-the-counter, herbs, and vitamins)
(Document if no medications or supplements are taken)
Name of Drug/Supplement Dosage/Frequency Last Dose Taken Reason for Taking
• Describe any medical treatments you are receiving (e.g., breathing treatments, dialysis, wound dressing):
(Document if no medical treatments are received)
• Describe any allergies to medications, foods, medical products (e.g., latex, contrast, tape), or things in the environment.
Describe your symptoms and their frequency. (Document if there are no allergies)
Allergic To Reaction and frequency
PAST HEALTH HISTORY
Childhood Illnesses (Check all that apply):
Measles ❏ Mumps ❏ Rubella ❏ Chickenpox ❏
Pertussis ❏ Influenza ❏ Ear infections ❏ Throat infections ❏
Other (describe) ❏
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
, Chapter 2 Obtaining a Health History 3
List previous medical conditions, surgeries, hospitalizations, or injuries. (Document if none apply)
Name and Type Date Residual Problems
Immunization Date/s Immunization Date/s
Diphtheria, tetanus, acellular pertussis (DTaP) Haemophilus influenzae type b (Hib)
Hepatitis A (HepA) Hepatitis B (HepB)
Human papillomavirus (HPV) Influenza (IIV)
Inactivated poliomyelitis (IPV) Influenza live attenuate vaccine (LAIV)
Meningococcal serogroups A, C, W, Y Meningococcal serogroup B (MenB)
(MenACWY)
Measles, mumps, rubella (MMR) Pneumococcal conjugate vaccine (PCV13)
Pneumococcal polysaccharide vaccine (PPS23) Zoster recombinant (RZV)
Rotavirus (RV) Tetanus toxoid (Td)
Tetanus, diphtheria, acellular pertussis (Tdap) Varicella (VAR)
Zoster live (ZVL) Other
www.cdc.gov/vaccines/schedules. Accessed 1/27/20.
Last Examination Date Outcome
Last Physical
Last Vision
Last Dental
Other (describe)
Women Only
Last Pap Test
Last Mammogram
Men Only
Prostate Exam
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
,4 Chapter 2 Obtaining a Health History
Obstetric history
Last menstrual period (LMP) Date Outcome
Pregnancies Dates Gravida (number of pregnancies) ________
Para (number of births) ________
Abortion/miscarriage ________
FAMILY HISTORY
(Document age and current health of family members. If deceased, indicate age and cause of death.)
Person Age Current Health Person Age Current Health
Mother Father
Sister Brother
Sister Brother
Daughter Son
Daughter Son
Draw a genogram for your lab partner’s family history.
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
, Chapter 2 Obtaining a Health History 5
PERSONAL AND PSYCHOSOCIAL HISTORY
Personal Status
• How would you describe yourself? or How do you feel about yourself?
• Describe your cultural/religious affiliations and practices.
• Describe your education, occupational history, and work satisfaction.
• Describe your perception of adequate time for leisure and rest, hobbies and interests.
Family and Social Relationships
• Describe your satisfaction with interpersonal relationships including significant others, individuals in home, and
your role within family.
• Describe the state of health of these individuals. Describe social interactions with friends, social organizations, or
religious groups.
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
, 6 Chapter 2 Obtaining a Health History
Diet/Nutrition
• Describe your appetite, typical food and fluid intake, and caffeine intake.
• Do you have any dietary restrictions or food intolerances?
• Have you had any changes in appetite or weight; changes in taste of food; problems while eating, e.g., indigestion,
pain, difficulty chewing or swallowing? If yes, describe.
• Have you had experiences with overeating, sporadic eating, or intentional fasting? If yes, describe.
Functional Ability
Do you need any assistance performing any of the following activities?†
Dressing ❏ Toileting ❏ Bathing ❏ Eating ❏ Ambulating ❏
Shopping ❏ Cooking ❏ Housekeeping ❏ Managing finances ❏
†
If unable to perform independently, describe.
Mental Health
• Describe your sources of stress. How do you cope with these stresses?
• Have you had feelings of anxiety, depression, irritability, or anger? If yes, describe.
Tobacco, Alcohol, and Illicit Drug Use
Tobacco use: Y ❏ N ❏ Type: Daily use:
Alcohol intake: Y ❏ N ❏ Type: Drinks per day:
Illicit drug use: Y ❏ N ❏ Describe: Frequency:
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
,Preface
The purpose of this Laboratory Manual is to provide structure for students as they practice with classmates acting as
patients to obtain health histories and perform physical examinations.
• The History contains questions about the patient’s Present health state, Past health history, Family history, Personal
and psychosocial history, and Review of Systems with space to document findings. In addition to learning how to
obtain a health history, students learn medical terminology, such as documenting “edema” when patients report
“swelling.”
A table is provided at the end of Chapter 2 to help students learn this terminology. Also, the Review of Systems in
chapters containing a health history uses lay terminology followed by medical terminology in parentheses to help
students learn these terms.
• The Examination section in Chapters 6–17, and 19–22 provides techniques performed in the left column with
space for documenting findings in the right column. Techniques for Special Circumstances have been integrated
within the Routine Techniques. Each examination technique is numbered to facilitate discussion of the skills by
number rather than naming the entire skill. These skills are written to direct the student; thus, the verbs are second
person with an implied “you,” e.g., (You) PERFORM hand hygiene.
• The Clinical Judgment that follows the history and examination sections uses the first two layers of the Clinical
Judgment Measurement Model to help students analyze data. These include: 1) Recognize cues for this patient.
Identify relevant findings from the history and examination and 2) Analyze cues. Organize and link the recognized
cues to the patient’s clinical presentation.
• A Performance Check List for examination skills has been added following each examination section in Chapters
7–17 and 22 as a structure to evaluate students. There are four descriptors of performance: Correct (C), Incomplete
(Inc), Incorrect (I), and Not performed (NP). Skills in the Check List are numbered the same as those in the exam-
ination section. These skills are written to direct the evaluator; thus, the verbs are present tense, third person with
an implied “he or she”, e.g., (He/She) PERFORMS hand hygiene.
• Following the Skills Performance Check List is an Implementation checklist that allows an appraisal of the student’s
implementation of the examination including assembly and use of equipment, the organization of the examination,
the confidence demonstrated by the student, and the student’s interaction with the “patient.” These skills are written
to direct the evaluator who assesses the implementation of the examination; thus, the verbs are past tense, third
person with an implied “he or she”, e.g., (He/She) Assembled needed equipment.
• At the end of the Check List there is space to tally the number from each category of descriptors in each of the
categories in Examination and Implementation.
• There are no laboratory activities for Chapters 1, 18, 23, and 24.
iii
,
,Contents
Chapter 2 Obtaining a Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 3 Techniques and Equipment for Physical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Chapter 4 General Inspection and Measurement of Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Chapter 5 Cultural Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Chapter 6 Pain Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Chapter 7 Mental Health Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Chapter 8 Nutritional Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Chapter 9 Skin, Hair, and Nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Chapter 10 Head, Eyes, Ears, Nose, and Throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Chapter 11 Lungs and Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Chapter 12 Heart and Peripheral Vascular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Chapter 13 Abdomen and Gastrointestinal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Chapter 14 Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Chapter 15 Neurologic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Chapter 16 Breasts and Axillae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Chapter 17 Reproductive System and the Perineum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Chapter 19 Assessment of the Infant, Child, and Adolescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Chapter 20 Assessment of the Pregnant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chapter 21 Assessment of the Older Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Chapter 22 Conducting a Head-to-Toe Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
v
,Student Name ____________________________________________________________ Date _________________________
CHAPTER 2 Obtaining a Health History
With your lab partner assuming the role of a patient, conduct a comprehensive history. Your “student patient” may role-play
a person with particular related symptoms and history.
HISTORY
BIOGRAPHIC DATA
Date Name Preferred name Sex Gender Identity
Male Male
Female Female
Both
Neither
Date of Age Race/Ethnicity Religion Language(s)
birth
Marital status Occupation
S M D W
REASON FOR SEEKING CARE (Presenting problem)
HISTORY OF PRESENT ILLNESS
Symptom Analysis of Presenting Problem (Onset, Location, Duration, Characteristics, Aggravating factors, Related
symptoms, Treatment, Severity)
PRESENT HEALTH STATUS
• Describe your current health conditions.
ο How long have you had these conditions?
ο How have these health conditions affected your daily activities?
Copyright © 2022 Elsevier, Inc. All Rights Reserved. 1
,2 Chapter 2 Obtaining a Health History
• What medications or supplements do you take? (Include prescription, over-the-counter, herbs, and vitamins)
(Document if no medications or supplements are taken)
Name of Drug/Supplement Dosage/Frequency Last Dose Taken Reason for Taking
• Describe any medical treatments you are receiving (e.g., breathing treatments, dialysis, wound dressing):
(Document if no medical treatments are received)
• Describe any allergies to medications, foods, medical products (e.g., latex, contrast, tape), or things in the environment.
Describe your symptoms and their frequency. (Document if there are no allergies)
Allergic To Reaction and frequency
PAST HEALTH HISTORY
Childhood Illnesses (Check all that apply):
Measles ❏ Mumps ❏ Rubella ❏ Chickenpox ❏
Pertussis ❏ Influenza ❏ Ear infections ❏ Throat infections ❏
Other (describe) ❏
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
, Chapter 2 Obtaining a Health History 3
List previous medical conditions, surgeries, hospitalizations, or injuries. (Document if none apply)
Name and Type Date Residual Problems
Immunization Date/s Immunization Date/s
Diphtheria, tetanus, acellular pertussis (DTaP) Haemophilus influenzae type b (Hib)
Hepatitis A (HepA) Hepatitis B (HepB)
Human papillomavirus (HPV) Influenza (IIV)
Inactivated poliomyelitis (IPV) Influenza live attenuate vaccine (LAIV)
Meningococcal serogroups A, C, W, Y Meningococcal serogroup B (MenB)
(MenACWY)
Measles, mumps, rubella (MMR) Pneumococcal conjugate vaccine (PCV13)
Pneumococcal polysaccharide vaccine (PPS23) Zoster recombinant (RZV)
Rotavirus (RV) Tetanus toxoid (Td)
Tetanus, diphtheria, acellular pertussis (Tdap) Varicella (VAR)
Zoster live (ZVL) Other
www.cdc.gov/vaccines/schedules. Accessed 1/27/20.
Last Examination Date Outcome
Last Physical
Last Vision
Last Dental
Other (describe)
Women Only
Last Pap Test
Last Mammogram
Men Only
Prostate Exam
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
,4 Chapter 2 Obtaining a Health History
Obstetric history
Last menstrual period (LMP) Date Outcome
Pregnancies Dates Gravida (number of pregnancies) ________
Para (number of births) ________
Abortion/miscarriage ________
FAMILY HISTORY
(Document age and current health of family members. If deceased, indicate age and cause of death.)
Person Age Current Health Person Age Current Health
Mother Father
Sister Brother
Sister Brother
Daughter Son
Daughter Son
Draw a genogram for your lab partner’s family history.
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
, Chapter 2 Obtaining a Health History 5
PERSONAL AND PSYCHOSOCIAL HISTORY
Personal Status
• How would you describe yourself? or How do you feel about yourself?
• Describe your cultural/religious affiliations and practices.
• Describe your education, occupational history, and work satisfaction.
• Describe your perception of adequate time for leisure and rest, hobbies and interests.
Family and Social Relationships
• Describe your satisfaction with interpersonal relationships including significant others, individuals in home, and
your role within family.
• Describe the state of health of these individuals. Describe social interactions with friends, social organizations, or
religious groups.
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
, 6 Chapter 2 Obtaining a Health History
Diet/Nutrition
• Describe your appetite, typical food and fluid intake, and caffeine intake.
• Do you have any dietary restrictions or food intolerances?
• Have you had any changes in appetite or weight; changes in taste of food; problems while eating, e.g., indigestion,
pain, difficulty chewing or swallowing? If yes, describe.
• Have you had experiences with overeating, sporadic eating, or intentional fasting? If yes, describe.
Functional Ability
Do you need any assistance performing any of the following activities?†
Dressing ❏ Toileting ❏ Bathing ❏ Eating ❏ Ambulating ❏
Shopping ❏ Cooking ❏ Housekeeping ❏ Managing finances ❏
†
If unable to perform independently, describe.
Mental Health
• Describe your sources of stress. How do you cope with these stresses?
• Have you had feelings of anxiety, depression, irritability, or anger? If yes, describe.
Tobacco, Alcohol, and Illicit Drug Use
Tobacco use: Y ❏ N ❏ Type: Daily use:
Alcohol intake: Y ❏ N ❏ Type: Drinks per day:
Illicit drug use: Y ❏ N ❏ Describe: Frequency:
Copyright © 2022 Elsevier, Inc. All Rights Reserved.
