This document provides information on assessing different body systems including respiratory, cardiovascular, gastrointestinal, and genitourinary systems. It discusses collecting relevant history, performing a physical examination, and ordering appropriate diagnostic tests for each system. The history sections cover current health issues, past medical history, family history, and psycho-social factors. The physical examinations describe inspection techniques like auscultation of the lungs and palpation of the abdomen. Common complaints, exam findings, and potential diagnostic tests are also outlined for each assessment.

1. ASSESSMENT
ANANYA BISWAS

2. RESPIRATOR
Y
ASSESSMENT

3. ASSESSMENT
ON
RESPIRATORY SYSTEM
 History
 Physical examination
 Investigation and diagnostic tests

4. History
 Identification data
 Current health
 Past health history
 Family health history
 Psycho-social history
 Review of system

5.  Identification data :
Name
Age
Gender
Living situations

6.  Current health :
o Chest pain -
1. may associated with pulmonary, cardiac, gastrointestinal problem
2. determine location, duration, intensity of chest pain
3. Pleuritic pain – sharp, stabbing pain that occur at one site on chest wall and increase
the chest wall movement and deep breathing.
4. Angina pectoris – an aching, heavy, squeezing sensation with pressure or tightness in
the substernal area and radiate into the neck or arm.
o Dyspnea -
1. difficulty in breathing.
2. shortness of breathing, suffocation, tightness, being breathless

7. o Cough -
1. note when and how cough begun,
2. how long the cough been present,
3. characteristic – dry, hoarse, congested, wheezy,
4. Sputum – color, consistency, odour, amount
5. hemoptysis - is simply a medical term for coughing up blood.
Causes of hemoptysis include chronic bronchitis, bronchiectasis,
pulmonary embolism, pneumonia, lung cancer, lung abscesses.
o Wheezing-
1. sound produces when air passes through partially obstructed or narrowed
airway.
2. complain of chest tightness or chest discomfort.

8. o Shortness of breathing -
1. Onset
2. Duration
3. Severity
4. Characteristic
o Other complaints -
1. Sweating
2. Dizziness
3. Limb pain
4. Exercise intolerance

9. Past medical history
1. data regarding common childhood diseases, congenital history and vaccinations
2. any history of Tuberculosis, Bronchitis, Influenza, Asthma, Pneumonia
 Smoking history
 Alcohol use- frequency and amount
 Allergies history
precipitating and aggravating factors –such as foods, medications, pollens, smoke,
fumes, dust
 Surgical history - history of any surgical procedure
 Medication

10. Family history
1. history of hereditary disease
2. living with person with infectious disease
Psycho-social history
1. Environment
2. Work environment
3. Occupation
4. Dietary habits
5. Exercise

11.  Physical examination
 Inspection-
1. general inspection :
- evidence of respiratory distress at rest or when walking, talking,
-evidence of other respiratory symptoms
2. Hands :
-finger clubbing
-cyanosis
-tremor
3. Nose : -patent
4. Neck :
- lymph node
- Goitre, jugular vein

12. Chest
Chest shape – normal; Barrel chest; Pectus carinatum (pigeon's chest); Pectus excavatum (funnel chest);
Scoliosis; lordosis; kyphosis
 Chest movement – paradoxical movement
 Respiration rate, rhythm, pattern, depth.
 Pursed lip breathing
 Tripod position - a patient who is seen taking the tripod position on their own is an indication that the
patient may be in respiratory distress.
 Nature of breathing -
Kussmaul's breathing- deep & laboured breathing; associated with the metabolic acidosis
Cheyne-stokes breathing- progressively deeper breathing

16.  Palpation -
1. Lymph node
2. Air entry – bilaterally equal / unequal
3. Tactile fremitus - ( use ulnar side of the hand, place it at various levels over the back, each time asking
patient to say ninety-nine. Note the sound transmitted.
If fremitus is increased indicates inflamed lung tissue caused by pneumonia
If it is decreased that suggest air or fluid in the pleural spaces, )

17. 

18.  Auscultation
Lung sound – normal / abnormal
Normal-
1. Bronchial - heard over the tracheal area, sound is high pitched and loud. Inspiration slightly
shorter than expiration.
2. Broncho-vesicular – heard over bronchi, sound is medium pitch. Inspiration is equal for
inspiration.
3. Vesicular – heard through peripheral lung fields, sound is soft with the low pitch. Inspiration
slightly greater than expiration.

20. 
6. Stridor- a harsh, vibrating, shrill sound is produced during respiration as heard in upper airway
obstruction. Eg- laryngitis.
7. Stertorous- noisy breathing,snorings sound are made by the air passage through the secretion as seen in
acute alcoholism

21.  INVESIGATION -

22. CARDIO-
VASCULAR
ASSESSMENT

23. ASSESSMENT
ON
CARDIO-VASCULAR SYSTEM
 History
 Physical examination
 Investigation and diagnostic tests

24. HISTORY COLLECTION
 data
 Current health history
 Past health history
 Family health history
 Psycho-social history

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26.  Cough -
 1. note when and how cough begun,
 2. how long the cough been present,
 3. characteristic – dry, hoarse, congested, wheezy,
 4. Sputum – color, consistency, odour, amount
 5. hemoptysis - is simply a medical term for coughing up blood.
 Causes of hemoptysis include chronic bronchitis, bronchiectasis, pulmonary embolism,
pneumonia, lung cancer, lung abscesses.
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27.  Dyspnea -
 1. difficulty in breathing.
 2. shortness of breathing, suffocation, tightness,
 3. being breathless I middle of night.
 Wheezing-
 1. sound produces when air passes through partially obstructed or
narrowed airway.
 2. complain of chest tightness or chest discomfort.
 Other complaints -
 1. Sweating
 2. Dizziness
 3. Limb pain
 4. Exercise intolerance

28.  Past medical history
 1. data regarding common childhood diseases, congenital history and vaccinations
 2. any history of Tuberculosis, Bronchitis, Influenza, Asthma, Pneumonia
 Smoking history
 Alcohol use- frequency and amount
 Allergies history
 precipitating and aggravating factors –such as foods, medications, pollens, smoke, fumes,
dust
 Surgical history - history of any surgical procedure
 Medication

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 is when the increased pressure of the superior vena cava
causes the jugular vein to bulge, making it most visible on the right side of a person's neck
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34. GASTRO-
INTESTINAL
ASSESSMEN
T

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36. HISTORY
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37. 
Abdominal pain-

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42. PHYSICAL EXAMINATION
 INSPECTION -
 General inspection-
1. Wasting
2. Jaundice
 System specific- Hands :
1.Nails ( clubbing / leuconychia )
2.Palmar erythema
3.Dupuytren's contracture
4.Hepatic flap
 Arms :
1.Spider naevi
2.Brusing
3.Wasting
4.Scratch marks (chronic cholestasis)

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48. GENITO-
URINARY
ASSESSMEN
T

49. ASSESSMENT OF GU SYSTEM
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