Health Assessment and Physical Examination

HEALTH ASSESSMENT ● Preparation of the setting, oneself

● a systematic method of collecting and the patient for the PE (Physical
subjective and objective data to Examination)
establish a patient’s overall level of ● Performance of IPPA (Inspection,
functioning in order to make a Palpation, Percussion, Auscultation)
professional clinical judgment. except for abdominal assessment
● All assessments involve 2 kinds of which uses IAPePa (Inspection,
data: Auscultation, Percussion, Palpation).
○ Objective Data
○ Subjective Data HEALTH HISTORY TAKING

Goals
● To establish rapport and trusting
relationship
● To gather information
● To offer information

Sources of Data
Primary
● Client, unless confused, too young,
or too ill to participate in an interview
Secondary
● Family members/caregivers/support
people, old medical or health
records, and results of laboratory
and diagnostics

Components of the Comprehensive

Health History
Identifying data
● such as age, gender, occupation,
Special Considerations marital status
The clinician should have a basic ● source of the history: patient
knowledge in the following: ● If appropriate, establish a source of
● Anatomy and Physiology referral because a written report may
● Effective interviewing skills be needed.
● Types and operation of equipment
needed for a particular examination.
Chief complaint Past Health History
● One or more symptoms or concerns ● lists childhood illnesses, then adult
causing the client to seek care. illnesses in each of the four (4)
areas:
Present Illness ○ Medical
● amplifies the chief complaint; ○ Surgical
describes how each symptom ○ Obstetric/Gynecologic
developed ○ Psychiatric
● client’s thoughts and feelings about ● includes health maintenance
the illness practices such as immunizations,
● pulls in relevant portions in the screening tests, lifestyle issues, and
Review of Systems that help clarify home safety
the differential diagnosis.
● may include medications, allergies, Family History
habits of smoking and alcohol, which ● outlines or diagrams age and health,
are pertinent to the present illness or age and cause of death, of
siblings, parents, and grandparents
7 Attributes of Symptom ● documents presence or absence of
● Location specific illnesses in family, such as
● Quality hypertension, diabetes, or type of
● Quantity/Severity cancer
● Timing, including onset, duration and
frequency Personal and Social History
● Setting ● describes educational level, family of
● Aggravating and relieving factors origin, current household, personal
● Associated symptoms interests, and lifestyle
Old Cart ● captures the patient’s personality
O- nset and interests, sources of support,
L- ocation coping style, strengths, and
D- uration concerns.
C- haracter ● Data about the client’s lifestyle with
A- ggravating and Alleviating factors a focus on factors that may impact
R- adiation health.
T- iming ● Information about alcohol, drug, and
OPQRST tobacco use; sexual practices;
O- nset tattoos; body piercing; travel history;
P- alliating and Provoking factors and work setting to identify
Q- uality occupational hazards
R- adiation
S- ite and Severity Review of Systems
T-iming ● documents the presence or absence
of common symptoms related to
each of the major body systems.
 PHYSICAL EXAMINATION Equipment in Physical Examination
● organized, systematic process of
collecting objective data about the
client’s heath based upon the head
to toe general systems examination.

Purposes
● Determine the following:
○ Objective data
○ The level of a client’s health
○ Possible anomalies
○ Whether the findings are
Positioning in Health and Physical
normal for the client
Assessment
○ Comparison of findings with
client’s personal and social
history
● Evaluate the client’s health and offer
a baseline for comparison
● Supplement, confirm or refute data
obtained in health history
● Obtain data that will help establish
diagnosis and plans of care

General Principles
Cardinal Techniques in Physical
● Gather equipment needed for the
Examination
examination.
Inspection
● Use the senses of sight, smell,
● The use of vision to distinguish
touch, and hearing to collect data.
normal from abnormal findings.
● Assessment includes inspection,
● It is important to know what to
palpation, percussion, and
consider normal for patients of
auscultation.
different age, gender, or cultural
group.
Steps in Preparing for the
● To inspect body parts accurately
Physical Examination
follow these principles:
1. Reflect on your approach to the
○ Make sure that adequate
patient.
lighting is available.
2. Adjust the lighting and the
○ Position and expose the
environment.
necessary body parts so that
3. Check your equipment.
you can view all surfaces.
4. Make the patient comfortable.
○ Inspect each area for size,
5. Observe standard and universal
shape, color, symmetry,
precautions.
position, and abnormalities.
6. Choose the sequence, scope, and
○ When possible, compare
positioning of the examination.
each area inspected with the
 same area on the opposite
side of the body.
○ Do not hurry inspection. Pay
attention to detail.
Palpation
● Involves the use of the hands to
touch body parts and make sensitive
assessments.
● It typically occurs right after
inspection.
● However, when examining the
abdomen, palpation occurs after
auscultation.
Principles of Palpation
● Keep fingernails short.
● Perform hand hygiene and warm the
hands before touching the patient.
● Assist the client to relax and position
comfortably.
● Implement light palpation first,
followed by deep palpation if
qualified to perform this technique.
● Palpate tender or painful areas last;
observe for grimacing, response to
initiation or release of pressure, and
reports of discomfort or pain.
● Assess all four quadrants of the
abdomen.
Types
● Light palpation depresses the skin 1
to 2 cm (1/2 to 3⁄4 inch).
● Deep palpation depresses the skin 3
to 5 cm.
Percussion
● involves tapping the client’s skin to
assess underlying structures and to
determine vibrations and sounds r/t
intensity, duration, pitch, quality, and
location.
● provides information r/t the presence
of air, fluid, or solid masses as well
as organ size, shape and position.
Auscultation
● involves listening to sounds
produced by the body, such as
heart, lung, or bowel sounds.
○ Direct - unaided ears
○ Indirect - use of stethoscope
Head to Toe Assessments
● Skin, Hair, and Nails
● Head, Neck and Lymph nodes
● Eyes, Ears, Nose, Mouth and Throat
● Lungs
● Heart and Peripheral Vascular
● Breasts and Axillae
● Abdomen
● Nervous system
Skin, Hair and Nails Full-body Skin Exam
● Involves inspection and palpation Patient Seated
Health History:
Common or concerning symptoms:
● Hair loss
● Rash
● Moles

Equipment
● Millimeter, ruler, or tape measure
● Clean gloves
● Magnifying glass
● Dermoscopy

Examination Techniques
1. Perform a full-body, and integrated skin
examinations in the context of the overall
physical examination
2. Position the patient. Choose from any of
these 2 positions:
● Sitting position
● Supine and prone position
3. Inspect and palpate the skin. Note these
characteristics:
● Color (hyper/hypopigmentation,
redness, pallor, cyanosis, jaundice)
● Moisture (dry, sweating, oily)
● Temperature (generalized/localized
warmth, coolness)
● Texture (rough)
● Mobility and turgor
● Lesions (anatomical location and
distribution, patterns and shape,
type, and color)
Patient Supine and Prone Exposed areas
● Limited to areas exposed to the air
or sun
Intertriginous
● Limited to areas where skin comes
in contact with itself

Lesion Configurations

SKIN
Skin Color Variations Characteristics of Skin Color
Cyanosis
● Mottled bluish coloration
Erythema
● Redness
Pallor
● Pale, whitish coloration
Jaundice
● Yellow coloration

Lesion shapes

Lesion Distribution Skin Turgor

Generalized ● To test skin turgor, pinch a large fold
● Distributed all over the body of skin and assess the ability of the
Regionalized skin to return to its place when
● Limited to one area of the body released
Localized ● Poor turgor occurs in severe
● Sharply limited to a specific area dehydration or extreme weight loss
Scattered ● Skin with decreased turgor remains
● Dispersed either densely or widely elevated after being pulled up and
release
Primary Skin Lesions Plaque
Flat, Non Palpable Lesions w/ changes in ● Elevated superficial lesion by 1 cm
color or larger, often formed by
Macule coalescence
● Small flat spot, up to 1 cm ● Ex: Psoriasis
● Ex: Hemangioma, Vitiligo

Nodule
Patch ● Knot-like lesion larger than 0.5 cm,
● Flat spot. 1 cm or larger deeper and more firm than a papule
● Ex: Cafe-au-lait spot ● Ex: Dermatofibroma

Palpable Elevations: Solid Bumps Cyst

Patch ● Nodule filled with expressible
● Up to 1 cm material. Either liquid or semisolid
● Ex: An elevated nevus ● Ex: Epidermal inclusion cyst

Pustule
● Filled with pus (yellow proteinaceous
fluid filled with neutrophils)
● Ex: Acne, small pox

Bulla
● 1 cm or larger, filled with serous fluid
● Ex: Insect bite
 Trichotillomania
Tinea Capitis
HAIR
● Inspect and palpate the hair. Note
its:
○ Quantity (thin, thick)
○ Distribution (e.g. diffuse,
patchy, total alopecia)
○ Texture (coarse: hypo, fine:
hyper)
Capillary Refill Test
Alopecia Areata
● Clearly demarcated round or oval
patches of hair loss, usually affecting
young adults and children. There is
no visible scaling or inflammation.
● Hair loss from pulling, plucking, or
twisting hair.
● Hair shafts are broken and of
varying lengths.
● More common in children, often in
settings of family or psychosocial
stress
● Round scaling patches of alopecia.
● Hairs are broken off close to the
surface of the scalp
● Usually caused by fungal infection
from Trichophyton tonsurans from
humans, microsporum canis from
dogs or cats.
● Mimics seborrheic dermatitis.
NAILS
● Inspect and palpate the fingernails
and toenails. Note the:
○ Color
○ Shape
○ Any lesions
● Depress the nail bed to produce
blanching
● Release and observe for the return
of color
● Color will return within 3 seconds if
arterial capillary perfusion is normal
 Terry’s Nails
● Whitish with a distal band
of reddish brown. Seen in
aging and some chronic
diseases.

Leukonychia
● White spots caused by
trauma. They grow out
with nail(s).

Transverse White lines

● Curved white lines
similar to curve of
lunula. They follow an
illness and grow out with
Normal Nail nails.
● Has an angle of approximately 160
degrees between the fingernail and
nail base
● Nail feels firm when palpated

Findings in or Near the nails

Clubbing
● Dorsal phalanx
rounded and
bulbous; convexity of
nail plate increased.
Angle between plate and proximal
nail fold increased to 180° or more.
Proximal nail folds feel spongy.
Many causes, including chronic
hypoxia and lung cancer.
Paronychia
● Inflammation of
proximal and lateral
nail folds, acute or
chronic. Folds red,
swollen, may be tender.
Onycholysis
● Painless separation of nail plate
from nail bed, starting distally. Many
causes.
Common/Concerning Symptoms
● Headache
● Change in vision: blurred vision, loss
of vision, floaters, flashing lights
● Eye pain, redness, or tearing
● Double vision (diplopia)
● Hearing loss, earache, ringing in the
ears (tinnitus)
● Dizziness and vertigo
● Nosebleed (epistaxis)
● Sore throat, hoarseness
● Swollen glands
● Goiter

Examination Techniques
The Head Eyes, Ears, Nose, Mouth, and Throat
1. Inspect and palpate the: Eyes
● Hair, including quantity, distribution, ● Involves inspection, palpation,
and texture vision-testing procedures
● Scalp, including lumps, lesions, nevi, Ears
scaliness ● involves inspection, palpation,
● Skull, including size and contour hearing tests, and the use of an
● Face, including symmetry and facial otoscope
expression Nose, Mouth, and Throat
● Skin, including color, texture, hair ● involves inspection and palpation
distribution and lesions
EYES
The Neck Important Areas of Eye Examination
1. Inspect the neck ● Visual acuity
2. Palpate the lymph nodes ● Visual fields
3. Inspect and palpate the position of the ● Conjunctiva and sclera
trachea ● Cornea, lens, and pupils
4. Inspect the thyroid gland ● Extraocular movements
● At rest ● Fundi, including: Optic disc and cup,
● As patient swallows water retina, and retinal vessels
5. From behind the patient, palpate the Equipment
thyroid gland, including the isthmus and ● Millimeter ruler
lateral lobes ● Penlight
● At rest ● Snellen eye chart
● As patient swallows water ● Opaque card
● Ophthalmoscope
The Eyes
1. Test the visual acuity in each eye.
2. Assess visual field, if indicated.
3. Inspect the:
● position and alignment of eyes
● eyebrows
● eyelids
● lacrimal apparatus 5. Assess the extraocular muscles by
● Cornea, iris, and lens observing:
● conjunctiva and sclera ● The corneal reflections from a
midline light
● The cardinal positions of gaze

Vision-Testing Procedures
Snellen Eye Chart
● Position the client in a well-lit spot 20
feet from the chart, with the chart at
eye level, and ask the client to read
the smallest line that he or she can
4. Examine pupils for: discern.
● Size, shape, and symmetry ● Instruct the client to leave on
● Light reactions: direct and glasses or leave in contact lenses.
consensual responses ● Normal visual acuity is 20/20
● The near reaction: pupillary (distance in feet at which the client is
constriction with gaze shift to near standing from the chart/distance in
objection; with convergence and feet at which a normal eye could
accommodation (lens become more have read that particular line).
convex) Confrontation Test
● Used to measure peripheral vision
and compare the client’s peripheral
vision with the examiner’s.
 ● The client covers one eye and looks
straight ahead; the examiner,
positioned 2 feet away, covers his or
her eye opposite the client’s covered
eye.
● The examiner advances a finger or
other small object in from the
periphery from several directions;
the client should see the object at
the same time the examiner does.
Corneal light reflex
● Used to assess for parallel
alignment of the axes of the eyes
● Client is asked to gaze straight
ahead as the examiner holds a light
about 12 inches from the client
● The examiner looks for reflection of
the light on the corneas in exactly
the same spot in each eye
Color Vision
● Ishihara chart is a tool used to
assess color vision; it determines the
client’s ability to distinguish a pattern
of color (a number) in a series of
color plates.
● The examiner tests each eye
separately and asks the client to
identify the number that he or she
sees on the chart.
● The ability to read the number
correctly depends on the normal
functioning of color vision.
Ophthalmoscopy/Fundoscopy
● An ophthalmoscope is used to
inspect the fundus, including the
retina, choroids, optic nerve disc,
macula, fovea centralis, and retinal
vessels.
● The examiner inspects the size,
color, and clarity of the disc, the
integrity of the vessels, and the
appearance of the macula, and
fovea and looks for retinal lesions
● Performed in a darkened room
● The client’s eyeglasses are removed
(contact lenses are left in place)
● The examiner and the client face
each other with the eyes at the same
height, the ophthalmoscope light is
switched on, and the lens is rotated
to 0.
● As the client gazes straight ahead
with both eyes open, the examiner
(standing about 10 inches from the
client and about 25 degrees lateral
to the client’s central line of vision)
shines the light on the pupil.
● A bright-orange glow (red reflex) can
be seen by the examiner; the
examiner slowly moves toward the
pupil, focusing on the red reflex.
● Rotating the lens on the
ophthalmoscope, the examiner
brings the internal structures into
focus.
EARS
Health History
● Difficulty hearing, earaches,
drainage from the ears, dizziness,
ringing in the ears, exposure to
environment noise, use of a hearing
aid, medications being taken, history
of ear problems or infections
Equipment
● Tuning fork
● Otoscope with
several sizes of
ear specula
The Ears
Examine on each side:
The Auricle
● Inspect the auricle.
● If you suspect otitis:
▪ Move the auricle up and down, and
press on the tragus.
▪ Press firmly behind the ear.
The Ear Canal and Ear Drum Otoscopic Exam
● Pull the auricle up back, and slightly ● An otoscope is used; for best
out. Inspect, through an otoscope visualization, the largest speculum
speculum: that fits comfortably into the client’s
▪ The canal ear canal should be used.
▪ The eardrum ● The examiner asks the client to tilt
the head slightly away, to the
opposite shoulder; next the
examiner pulls the pinna up and
back (on an adult or older child),
holds the otoscope upside down,
and inserts the speculum slightly
down and forward, approximately
half an inch, into the ear canal.
Hearing/Auditory Acuity
1. Assess auditory acuity to whispered or
NOSE
spoken voice.
Health History
2. If hearing is diminished, use a 512 Hz
● Ask about discharge or nosebleed
tuning fork to:
(epistaxis); facial or sinus pain;
● test lateralization (Weber test). Place
history of frequent colds; altered
vibrating tuning fork on the vertex of
sense of smell; allergies;
the skull and check hearing.
medications being taken; history of
● compare air and bone conduction
nose trauma or surgery.
(Rinne test). Place vibrating tuning
fork on the mastoid bone, then
remove and check hearing.
Equipment MOUTH AND THROAT
● Nasal Speculum Health History
● Penlight ● Ask about the presence of sores or
lesions; bleeding from the gums or
Examination Techniques and Possible elsewhere; altered sense of taste;
Findings toothaches; use of dentures or other
appliances; tooth and mouth-care
hygiene habits; at-risk behaviors
(e.g., smoking, alcohol
consumption); history of infection,
trauma, or surgery

Equipment
● Clean gloves
● Tongue depressor
● 2 x 2 gauze pads
● Penlight

The Mouth
1. Using penlight and tongue depressor,
inspect the:
● lips
● oral mucosa
● gums
● teeth
● roof of the mouth
● tongue, including:
▪ papillae
▪ symmetry
▪ any lesions
● floor of the mouth
● pharynx, including:
▪ color or any exudate
▪ presence and size of tonsils
▪ symmetry of the soft palate as
patient says “ahh”