Physical Assessment

&
History taking
Week one Lecture No.1
 Definitions
❖ Assessment is the collection of data
about the individual health status and
the point of entry of an on going
process .
❖ From the data you make clinical
judgment or diagnosis about individual
health state or response to actual or
potential health problem.
❖ An organized assessment is the starting
point of all models of clinical reasoning
.
 :Collecting 4 types of data
1- Complete (total health) data base
▪ It includes complete health history and full physical
assessment
▪ Gathered in primary health care, acute hospital care
and clinic.
▪ It includes illness perception, functional ability,
activity of daily livings, health maintenance
behaviors …..etc
2- Episodic (Problem centered) data base
▪ Smaller in scope and more focused
▪ One problem or one system
▪ Used in all health care settings
 :Collecting 4 types of data
3- Follow up data base
▪ Identified problem evaluated at regular and
appropriate intervals
▪ Used in all health care settings
4- Emergency data base
▪ Rapid collection of data
▪ Concurrent with life saving measures
 The Purpose of health
history
• Gather the related information.
• Establish a trust relationship.
• Relax the patient.
• Offer information's
 Sources of the Information
❖ Patient.
❖ Family members
❖ Peers.
❖ Patient files.
 The Interview
❖ It is a meeting between you and your patient
❖ The meeting goal to record a complete health
history
❖ The first and most important part of data
collection
❖ Consider as being similar to forming a contract
❖ It includes
▪ Time and place of interview
▪ Purpose and length of interview
▪ Expectation of participation of each person
▪ Presence of any other people
▪ Confidentiality
▪ Cost
 The Interview
❖ When you have a successful interview you
will
▪ Gather complete and accurate data
▪ Establish rapport and trust
▪ Teach the person about the health state
▪ Build rapport for continuing therapeutic
relationship
▪ begin teaching for health promotion and
disease prevention
 Communication
Communication is the process that carries you
and patient through the interview
It is exchanging information so that each
person clearly understand the other
▪ Sending
▪ Receiving
▪ Internal factors
▪ External factors
 Communication
:Internal factors
▪ Liking others , warmth , caring, respect
▪ Empathy : feeling with the person rather
than feeling like the person
▪ The ability to listen
 Communication
External factors
• Ensure privacy
• Refuse interruption
• Preparing physical setting (room
temperature , sufficient lightening , reduce
noise , remove distracting objects, the
distance between you and the patient at 4-5
feet,arrange equal –status seating at eye
level.avoid facing a patient across a desk or
a table.
• Dress
• Note taking
▪ Disadvantages
▪ break eye contact
▪ shift your attention away from the person
▪ threatening the patient
Technique of Communication
▪ Introducing the interview
▪ The working phase :
▪ Open ended questions “tell me how can I help
you?
▪ Closed directed questions :ask for specific
information , yes or no questions
▪ Responses Assisting the narrative
(how you encourage pt to express feeling?):
▪ Facilitation
▪ Silence
▪ Reflection
▪ Empathy
▪ Clarification
Technique of Communication
▪ Confrontation
▪ Interpretation
▪ Explanation
▪ Summary
▪ In the first five response patient leads;
in the last four response you lead.
 Ten Traps of Interview
1. Providing false assurance or reassurance
2. Giving un wanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional JARGON
7. Using leading questions
8. Talking too much
9. Interrupting
10. Using Why questions
 Non verbal communication
▪ Physical appearance
▪ Posture
▪ Gesture
▪ Facial expressions
▪ Eye contact
▪ Voice
▪ Touch
 Closing the interview
▪ Should end gracefully
▪ Any abrupt closing can destroyed rapport
and leave patient with negative impression
of the whole interview
▪ Is there anything else you want to mention?
▪ Are there any questions you would like to ask?
▪ This gives the person last opportunity for
self expression
 Subjective & Objective Data

Subjective Data
What the patient tells you.
The history, from chief complaint
through review of system
Example Mrs. G is a 54 year old, reports
pressure over her left chest radiated to
left neck & arm.
 Subjective & Objective Data
Objective Data
What you detect during the examination
All physical examination findings
Example Mrs. G is an older, overweight.
Bp 160/ 80 mmHg, HR 90 b/m, RR 24 b/
m
 Complete health history
(Jarvis)
▪ Biographical data
▪ Source of History
▪ Reason for Seeking Care
▪ History of Present Illness
▪ Past Health
▪ Family History
▪ Review of Systems
▪ Functional Assessment ( Activities of Daily
Living)
▪ Perception of Health
 Comprehensive Adult Health
History
1- Initial Information
▪ Date and time of history
▪ Identifying data
▪ Source of history or
referral
▪ Reliability of historian
▪ Biographical data
▪ Sex
▪ Name
▪ Marital status
▪ Address
▪ Occupation
▪ Phone
▪ Religion
▪ Birth date
 Comprehensive Adult Health
History
2- Chief Complaint(s)
▪ Try to quote the patient own words
▪ eg. “ my stomach hurts and I feel awful”
▪ The one or more symptoms or concerns causing
the patient to seek care.
▪ Main symptom (s) or other abnormalities (may
be a sign or lab abnormality) which brought the
patient to medical attention and its duration.
 Comprehensive Adult Health
History
3- Present health or history of present illness
[HPI]
▪ This section of history is a complete, clear, and
chronologic account of the problems prompting
the patient to seek care
▪ The principle symptoms should be well-
▪ setting in which they occure
chracterize with description
▪ factorsof:
that aggravating or
▪ location, relieving
▪ quality ▪ associated factors
▪ quantity or severity
▪ timing [onset, duration, frequency]
 Analysis of Symptoms
• P Provokes What makes symptoms
better/worse?

• Q Quality What does pain feel like?

• R Region/Radiation Where & where does pain

go?

• S Severity On Scale of 1-10 (other scales)

• T Time When, How often, How

long?
 Comprehensive Adult Health
History
4- Past History
▪ Childhood illnesses
▪ Medical illnesses
▪ Surgical history [PSH],Operations
▪ Obstetric History
▪ Accidents or injuries
▪ Immunizations
▪ Allergies
▪ Medications [including OTC]
▪ Psychatric
 Comprehensive Adult Health
History
▪ History of allergy
▪ Any allergy to drugs, food, pollens, clothes
▪ Type of reaction: itching, urticaria, skin
rash, respiratory difficulty, eye
symptoms…
▪ Drug history
▪ Details of all recent drugs taken by the
patient
▪ Details of drugs taken in the past for long
periods
▪ Any reaction or side effects to drugs
 Comprehensive Adult Health
History
5- Family History
▪ History of similar diseases in family
members
▪ History of family diseases in the involved
system
▪ History of chronic illnesses in family
members
▪ History of major acute illnesses recently
 Comprehensive Adult Health
History
6- Personal & Social
History
Marital status and
children ADL
Level of education ▪ Bathing
Income ▪ Dressing
▪ Toileting
Living circumstances ▪ Eating
Recent jobs ▪ Housekeeping
Hobbies ▪ Shopping
▪ Cooking
Cigarette smoking ▪ Nutritional Status
Alcohol drinking
Drug abuse
 Comprehensive Adult Health
History
7- Systemic review
▪ Inquiry about all symptoms of the various systems
if they are positive or negative recently
▪ Head – to – Toe Assessment
▪ Body Systems Assessment
a. General:
▪ Fever
▪ General weakness
▪ Fatigue, malaise, anorexia
▪ Loss or gain of weight
 Systemic Review
:b. Skin
Skin rash, itching, pain, swellings, hair and -
.nails
c. Head, Eyes, Ear, Nose, Throught (HEENT)
d. Neck
e. Breast
:f. Respiratory system
URT symptoms: sneezing, nasal discharge,
nasal obstruction, sore throat, hoarseness of
voice, stridor
LRT symptoms: chest pain, shortness of
breath, cough, sputum, wheezing,
 Systemic Review
g. Cardiovascular symptoms:
Chest pain, shortness of breath, orthopnea,
paroxysmal nocturnal dyspnea, palpitation,
ankle swelling, syncopal attacks, fatigue,
intermittent claudication
h. Gastrointestinal symptoms
Difficulty or pain with swallowing, nausea,
vomiting, heartburn, regurgitation,
abdominal pain, abdominal distension,
constipation or diarrhea, anal pain or
discharge or itching, hematemesis, rectal
bleeding (hematochezia) or melena.
 Systemic Review
i. Urinary symptoms:
Renal pain, dysuria, frequency, disturbed
stream of micturition, discoloration of urine,
amount of urine
j. Genital:
in males: erectile dysfunction, ejaculation
In females: age of menarche, menopause,
regularity of menstruation, amount of
bleeding, menstrual pain, obstetric history.
k. Peripheral vascular
 Systemic Review
l. Musculoskeletal system:
▪ Pain, swelling, limitation of movements in
various joints.
▪ Muscle pain and muscle wasting
▪ Bone pains

m. Psychiatric
history of traumatizing events, anxiety,
depression, obsession, fear of certain
diseases, mental illnesses.
 Systemic Review
n. Neurological symptoms:
disturbance in level of consciousness,
headache, fits, special senses, speech, sleep,
motor deficits, sensory disturbances, gait,
sphincteric disturbances.
o. Endocrinological symptoms:
cold or heat intolerance, sweating, change
in weight, polyuria, polydipsia, general
weakness
p. Hematological:
pallor, general weakness and easy
fatigability, recurrent fevers, bleeding
 Document your findings
▪ Documentation forms vary per agency
▪ Your written records should facilitate clinical
reasoning and communicate essential information
to other health professional.
▪ Write the records ASAP
▪ During physical assessment make note immediately.
▪ Pay attention to order and degree of details
▪ The order should be consistent and obvious
▪ Degree should be related ton problem and not
redundant
▪ Use of standardized nursing admission assessment
forms
▪ Combines health history and physical assessment
separately
 Interview Milestones
• Getting ready: the approach to the interview.
• Learning about the patient: the sequence of
the interview.
• Building the relationship: the technique of
skilled interview.
• Adapting your interview to specific
situations.
• Sensitive topics that call special skills
• Societal aspects of interview.
 Getting ready: the approach to the
.interview
• Taking time for self reflection.
• Reviewing the medical record
• Setting goals for interview
• Review your clinical behaviors and
appearance
• Adjusting the environment
• Taking note
 Learning about the patient: the
sequence of the interview:
• Greeting the patient and establish rapport
• Establish the agenda
• Inviting the patient story
• Identifying and responding to the patients
emotional cues.
• Expand and clarifying the patients story.
• Generating and testing diagnosis hypothesis
• Creating a shared of the problem
• Negotiating a plan
• Planning for follow up and closing
 Building a therapeutic relationship: the
technique of skilled interviewing
• Building the relationship
• Active listening
• Guide questioning: options for expanding
and clarifying the patient story
• Nonverbal communication.
• Empathic response
• Reassurance
• Summarizing
• Empowering the patient.

Dr Murad Alkhalaileh
 Adapting your interview to specific
situation:
• The silent patient
• The confusing patient.
• The patient with altered capacity
• The talkative patient.
• The crying patient.
• The angry or disruption patient.
• The interview across a language barrier.
• The illiteracy patient or limited intelligence.
• The patient with impaired hearing or vision.
• The patient with personal problem.

Dr Murad Alkhalaileh
 Assessment techniques
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
 Inspection
Concentrated watching
Always come first
Close and careful visualization of the person
as a whole and of each body system
Ensure good lighting
 Palpation
▪ Follow and confirm points you noted during
inspection
▪ Light Vs Deep
▪ Bimanual: use of both hands to capture certain
body organ such as uterus, kidney
▪ Temperature, Texture, Moisture,Organ size and
location, Rigidity or spasticity, Crepitation &
Vibration, Position & Size, Presence of lumps or
masses Tenderness, or pain
 Percussion
▪ Tappin the person skin with short, sharp,
strokes to assess underlying structures for
location, size, density of underlying tissue.
▪ Direct Vs Indirect
▪ The stationary Hand
▪ The striking hand
 Auscultation
• Listening to sounds produced by the body
• Instrument: stethoscope (to skin)
• Diaphragm –high pitched sounds
Heart, Lungs, Abdomen
• Bell – low pitched sounds
Blood vessels
 General survey
Appearance
Age, skin color, facial features
Body Structure, nutrition, posture, position,
symmetry
Mobility - Gait, ROM
Behavior
Facial expression, mood/affect, speech, dress,
ygiene
Cognition
Level of Consciousness and Orientation
Include any signs of distress- facial grimacing,
breathing problems
 General survey
▪ Measure vital signs
▪ Calculating BMI,wt in kg /ht in m squared .
▪ Under weight < 18.5
▪ Normal 18.5-24.9
▪ Over weight 25-29.9
▪ Obesity 1……. 30-34.9
▪ 2……. 35-39.9
▪ Extreme obesity >= 40