Introduction to Assessment -introduction interview history taking.pptx

MU, School of Nursing © February, 2025 1
Introduction to health assessment
By :Desta Siyoum (Assistant professor)
For 2nd
Year Psychiatry Nursing Students
School of Nursing, CHS, Mekelle University
Nursing Health Assessment

Course description
The course is designed:
 to provide adequate level of knowledge and
skills necessary for assessing the health status
of the client.
 to perform physical examination in a systematic
manner so as to determine the health status of
individuals

Course contents
Nursing Health Assessment- I
 Introduction to Health Assessment
 Assessment of Musculoskeletal system
 Examination of thorax and the lungs
 Health assessment of the integumentary system
Nursing Health Assessment- II
Assessment of cardiovascular system
Assessment of Genitourinary system
 Assessment of nervous system

Course objectives
General objective
After completing this course, the student will be
able to:
 assess the client using proper history taking,
 performing complete physical examination,
 identify actual & potential health problem of the
patient.

Evaluation
Individual assignment -----20%
Exam -----------------------50 %
Practical exam ----------------30%

References
1. Lynn S. Bickley, Peter G. Szilagyi, Richard M. Hoffman. Bates’ guide
to physical examination and history taking.13th
edition. Philadelphia:
Wolters Kluwer;2021
2. Carolyn Jarvis, Ann Eckhardt. Physical Examination & Health
Assessment. 8th
edition. St. Louis, Missouri: Elsevier Inc;2020
3. Michael Glynn, William M. Drake. Hutchison’s Clinical Methods an
integrated approach to clinical practice.24th
edition. St. Louis,
Missouri: Elsevier Ltd;2018
4. Sharon Jensen. Nursing health assessment: a best practice
approach. 3rd
edition. Philadelphia: Wolters Kluwer Health;2019

References
5. T. Heather Herdman, Shigemi Kamitsuru, Camila Lopes.
NANDA International, Inc Nursing Diagnoses Definitions and
Classification 2024–2026.13th
edition. New York: Thieme
Medical Publishers Inc;2024
6. Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr.
Nursing care plans : guidelines for individualizing client care
across the life span 10th
Edition. Philadelphia : F.A. Davis
Company;2019
7. Howard K. Butcher, Gloria M. Bulechek, Joanne M.
Dochterman,Cheryl M. Wagner. Nursing Interventions
Classification (NIC). 7th
Edition. St. Louis, Missouri : Elsevier,
Inc. ;2018

Introduction to Nursing Health Assessment
After completing this session , you will be able to:
 Define health assessment
 Identify the purpose of assessing.
 Identify the four major activities associated with the Assessment
phase.
 Differentiate objective and subjective data
 Compare the four types of health assessment
 Identify three methods of data collection
Identify different Skilled Interviewing Techniques
Discuss Components of the Comprehensive Health History

Health assessment
A systematic process of collecting, organizing,
analyzing and validating of data about the client’s
health status
is the systematic and continuous collection,
organization, validation, and documentation of data
(information)
Assessment Data Obtained From
History
Physical examination

Purpose of Health Assessment
Collect physiologic, psychological, sociocultural,
developmental & spiritual data about the client
Identify actual and potential health problems

Steps of health assessment
 has four major steps
1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4. Documentation of data

Collection of subjective data
Subjective data, also referred to as symptoms or covert
data,
 symptoms that can be elicited and verified only by the
client
Subjective data- what the person says about him/herself
during history taking
Example -Client states “I have had a rash on my ankle and
leg for the last two weeks”
A symptom is any subjective evidence of disease

Collection of objective data
Objective data, also referred to as signs or overt data
Objective data- what you observe by inspecting,
percussing, palpation & auscultating during the physical
examination
Example - You observe that a client has a bright red rash on
the dorsal side of the foot
A sign is any objective evidence of disease

Comparing subjective and objective data
Subjective data Objective data
Description  Data elicited and
verified by the client
 Data directly or indirectly observed through
measurement
Sources  Client  Observations and physical assessment
findings
 Documentation of assessments made in
client record
Methods used to
obtain data
 Client interview  Observation and physical examination
Skills needed to
obtain data
 Interview and
therapeutic–
communication skills
 Listening skills
 Inspection
 Palpation
 Percussion
 Auscultation
Examples  I have a headache  BP 180/100, apical pulse 80 and irregular

Rest and digest
 G is a 54-year-old hairdresser who reports pressure
over her left chest “like an elephant sitting there,”
which goes into her left neck and arm. G is a white
male, pleasant and cooperative.
 Blood pressure 160/80, heart rate 96 and regular,
respiratory rate 24, afebrile.
 What are the symptoms (subjective data)?
 What are the signs (objective data)?

Validating of data
Validation is the act of “double-checking” or verifying data
to confirm that it is accurate and factual.
Is a crucial part of assessment that often occurs along with
collection of subjective and objective data
Purpose of validation
Confirming or verifying that the subjective and objective
data are reliable & accurate
 to prevent documentation of inaccurate data

Validating of data…
Methods of validation:
Recheck your own data through a repeat assessment
Clarify data by asking additional questions
Verifying the data with another health care professional
Compare your objective findings with your subjective
findings to uncover discrepancies

Documentation of data
Thorough and accurate documentation is vital to ensure
valid conclusions are made when the data are analyzed
Purposes of documentation
Promote effective communication among health team
members
Provide health care team with a database that becomes
foundation for care of client
 Identify health problems, formulate nursing diagnoses,
plan immediate and ongoing interventions

Documentation of data….
Methods of documentation
Electronic health records (EHRs)
Paper based

Types of Health Assessment
Depending on the clinical situation
Initial assessment
Focused or problem-center assessment
Time lapsed assessment
Emergency assessment

Initial assessment
Performed at the time the patient enters the
health care facility.
Broad and leads us to a center of our diagnosis
The aim of initial assessment is collection of
data concerning actual or potential
dysfunction

Focused Assessment
For limited or short-term problems (seeking health care)
Collect “mini” database, smaller scope and more
focused than complete database
Concerns mainly one problem or one body system

Time lapsed assessment
It is the final assessment done after a period of time
This assessment is focused type.
Its aim is comparing the patient’s current status to
baseline data obtained previously after a period of time

Emergency assessment
 Urgent-rapid collection of crucial data that is compiled with
lifesaving measures
 Diagnosis must be swift & sure
 Once the person has been stabilized, a complete database
can be compiled
 If the patient is unresponsive, health care providers may
need to rely on family & friends

Types of Assessment

Data collection methods
Interview
Physical examination
Laboratory investigation
Imaging
26

Interview
Client -clinician interaction where by the clinician asks and the client
answers.
Phases of an interview
Preparatory phase
Introduction
Working phase
Termination
27

Preparatory phase
First step to be practiced.
Ensure environment is conducive
Arrange seating
28

Introduction
Introduces your self
Identifies purpose of interview
Ensure confidentiality/privacy

Working
Nurse gathers information
Excellent communication skills such as
 active listening ,
Eye contact ,
Open-ended questions etc. should be practiced.

Termination
Inform patient when nearing end of interview
Ensure patient knows what will happen with the
information.
Offers patient chance to add anything

Purpose of an interview
To establish a trusting relationship b/n the nurse and the
client.
Develop understanding about the patient condition.
Helps the patient feel understood.
Guides on which body parts or systems to focus during
physical examination.

Skilled Interviewing Techniques
1. Active or attentive listening
2. Guided questioning
3. Empathic responses
4. Summarization
5. Transitions
6. Partnering
7. Validation
8. Empowering the patient
9. Reassurance
10.Appropriate verbal communication
11. Appropriate nonverbal communication
33

1. Active or Attentive Listening
lies at the heart of the patient interview.
It means
carefully attending to what the patient is communicating,
connecting to the patient’s emotional state, and
using verbal and nonverbal skills to encourage the patient to
expand on his or her feelings and concerns.
 Focus on what the patient is telling you, both verbally and
nonverbally.
Sometimes one’s body language tells a different story from
one’s words.

2. Guided Questioning
 There are several ways to elicit more information without changing
the flow of the patient’s story.
Techniques of Guided Questioning
Moving from open-ended to focused questions
Using questioning that elicits a graded response
Asking a series of questions, one at a time
Offering multiple choices for answers
Clarifying what the patient means
Encouraging with continuers
Using echoing/repetition

Moving from Open-Ended to Focused Questions
Your questions should flow from general to specific.
Start with the most general questions like,
“How can I help?” or “What brings you in today?”
Then move to still open, but more focused,
questions like,
“Can you tell me more about what happened when
you took the medicine?”
Then pose closed questions like,
“Did the new medicine cause any problems?”

Moving from Open-Ended to Focused Questions…
Avoid leading questions that already contain an answer or
suggested response like:
“Has your pain been improving?” or
“You don’t have any blood in your stools, do you?”
If you ask, “Is your pain like a pressure?”
the patient answers yes.
 Adopt the more neutral “Please describe your pain.”

Questioning That Elicits a Graded
Response
Ask questions that require a graded
response rather than a yes-no answer.
Ex which one is better ?
“How many steps can you climb before
you get short of breath?”
“Do you get short of breath climbing
stairs?

Asking a Series of Questions, One at a Time
Be sure to ask one question at a time.
 Ex which one is better
“Any tuberculosis, diabetes, asthma, heart condition,
or high blood pressure in the family?”
“Do you have any of the following problems?” .

Offering Multiple Choices for Answers
Sometimes, patients need help in describing
their symptoms.
To minimize bias, offer multiple-choice answers:
“Which of the following words best describes
your pain: aching, sharp, pressing, burning,
shooting, or something else?”

Clarifying What the Patient
Means
Sometimes the patient’s history is difficult to understand.
 It is better to acknowledge confusion than to act like the
story makes sense.
To understand what the patient means, you need to request
clarification,
Ex “You said you were behaving just like your mother.
What did you mean?”

Encouraging with Continuers
Without even speaking, you can use posture and gestures
(nonverbal encouragements) or words (neutral utterances)
to encourage the patient to say more.
Ex
Pausing and nodding your head
 remaining silent, yet attentive and relaxed
Leaning forward
 making eye contact
 using phrases like “Uh-huh,” or “Go on,” or “I’m listening”

Echoing (Repetition)
 Simply repeating the patient’s last words, or echoing, encourages the patient to
elaborate on details and feelings.
 Echoing also demonstrates careful listening and a subtle connection with the
patient by using the same words.
 For example:
Patient: “The pain got worse and began to spread.” (Pause)
Response: “Spread?” (Pause)
Patient: “Yes, it went to my shoulder and down my left arm to the fingers. It was
so bad that I thought I was going to die.” (Pause)
Response: “Going to die?”
Patient: “Yes, it was just like the pain my father had when he had his heart
attack, and I was afraid the same thing was happening to me.”

Empathic responses
Empathy has been described as the capacity to identify with
the patient and feel the patient’s pain as your own, then
respond in a supportive manner.
Once the patient has shared these feelings, reply with
understanding and acceptance.
E.g.
“I understand your problem”
 it may be behavioral such as providing a piece of soft for a
patient in tears.

Summarization
 Giving a capsule summary of the patient’s story during the course of
the interview serves several purposes.
 It communicates that you have been listening carefully. It identifies
what you know and what you don’t know.
 Ex “Now, let me make sure that I have the full story. You said you’ve
had a cough for three days, that it’s especially bad at night, and that
you have started to bring up yellow phlegm. You have not had a
fever or felt short of breath”
 Following with an attentive pause or asking, “Anything else?”
allows the patient to add other information and correct any
misunderstandings.

Transitions
 Patients may be apprehensive during a healthcare visit.
 To put them more at ease, tell them when you are changing directions during
the interview.
 Just like signs along the highway, “signposting” transitions help prepare patients
for what comes next.
 As you move through the history and on to the physical examination, orient the
patient with brief transitional phrases like
“Now I’d like to ask some questions about your past health.”
“Before we move on to reviewing all your medications, was there anything else
about past health problems?”
“Now I would like to examine you. I will step out for a few minutes. Please
undress and put on this gown.”

Non-verbal Communication
Communication that does not involve speech
occurs continuously and provides important
clues to feelings and emotions.
Becoming more sensitive to nonverbal
messages allows you to both:
- to “read the patient” more effectively and
- to send messages of your own.

Partnering
When building rapport with patients, express
your commitment to an ongoing relationship.
Make patients feel that no matter what
happens, you will continue to provide their care.
Even as a student, especially in a hospital
setting, this support can make a big difference.

Validation
Another way to affirm the patient is to validate the
legitimacy of his or her emotional experience.
A patient caught in a car accident, even if uninjured, may
still feel very distressed.
Saying something like, “Your accident must have been
terrifying. Car accidents are always unsettling because they
remind us how vulnerable we are.
Perhaps that explains why you still feel upset validates the
patient’s response as legitimate and understandable

Empowering the Patient
 The clinician–patient relationship is inherently unequal.
 Patients have many reasons to feel vulnerable. They may be in pain or worried
about a symptom.
 Empowering the Patient: Techniques for Sharing Power
Evoke the patient’s perspective.
Convey interest in the person, not just the problem.
Follow the patient’s leads.
Elicit and validate emotional content.
Share information with the patient, especially at transition points during the
visit. Make your clinical reasoning transparent to the patient.
Reveal the limits of your knowledge.

Reassurance
 When you are talking with patients who are anxious or
upset, it is tempting to reassure them.
 The first step to effective reassurance is identifying and
accepting the patient’s feelings.
The actual reassurance comes much later after you have
completed the interview, the physical examination, and
perhaps some laboratory studies.
Reassurance is more appropriate when the patient feels that
problems have been fully understood and are being
addressed.

Appropriate verbal
communication
 Use Understandable Language
understandable language uses simple, recognizable and clear
words.
avoid the use of medical jargon, abbreviations or any complex
words or phrases.
 use Non-stigmatizing Language
On occasion, one may unintentionally use words or phrases during
the clinical interview which could be perceived by the patient as
dehumanizing, perpetuate stigma, and tend to marginalize rather
than support them.
For example, which one is better?
 “Do you still consider yourself a drug addict?”
 “Do you still consider yourself a person with an addiction to drugs?”

Appropriate nonverbal communication
 Just as you carefully observe the patient, the patient will be watching
you.
 convey the extent of your interest, attention, acceptance, and
understanding
 Forms of Nonverbal Communication
Body orientation toward and physical proximity to patient
 Gaze orientation (eye contact) toward patients
Head nodding with facial animation
Head nodding with gesture
Posture
Use of silence Use of touch

Approaches of Health Assessment
The systems approach -(medical model)
The functional health pattern (Gordon’s
approach)

Medical/System approach
Clinical tool that is used to collect and organize
clinical data based on body systems.
Components
History
Physical examination (PE)
System based examination

History taking
It is a process by which information is gained by
a clinician by asking specific questions to the
patient with the aim of obtaining information
useful in
formulating a diagnosis and
providing medical care to the patient

Importance of History Taking
 Obtaining an accurate history is the critical
first step in determining the etiology of a
patient's illness.
 Diagnosis in disease is based on
•Clinical history
•Physical Examination
•Investigations

History taking
 A large percentage of the time (80%), you will
actually be able make a diagnosis based on the
history alone.

Approach to history taking
Your look is important- Your dressing

Introduce your self and create a rapport

 Ensure consent has been gained.
 Maintain privacy and dignity.
 Ensure the patient is as comfortable as
possible
 Summarise each stage of the history taking
process.
 Involve the patient in the history taking
process

Be alert and pay full attention

If in a bad mood or distracted during history
taking, you can end up making a history rather
than taking a history”.

Components of the Comprehensive Health History
Patient’s profile
Chief complaint
History of the present illness
Past medical history
Family history
Socioeconomic history
System Review

Patients profile
Biographic data - name, age , sex, Religion,address,
birthplace, ,relationship status, ethnic origin ,Occupation
 Source of history
usually the patient, but can be a family member, caregiver
or friend, or the clinical record
Sample Statements:
Patient herself, who seems reliable
Patient's son, X, who seems reliable
Mrs. R , interpreter for Y, who does not speak Tigirigna

Chief Complaint(s)/( C/c)-
 Main reason for which the patient is trying to seek medical help
 Record these complaints in the patients' own words in chronological
order and with the duration.
 Make every attempt to quote the patient’s own words.
 Usually one, but could be more
 If there is more than one complaint, it should be written according to
chronological order
 Simple & brief
 Sometimes patients have no overt complaints, in which case you
should report their goals instead.

Chief Complaint(s)/( C/c)-
How to ask for chief complaint?
What brings your here?
How can I help you?
What seems to be the problem?
 Sample Statements:
“Chest pain for 2 hours”
“My stomach hurts and I feel awful.”
 “I have come for my regular checkup”
I feel like an elephant is sitting on my chest.”

History of the present illness-HPI
Elaborate on the chief complaint in detail
a chronologic record of the reason for seeking care, from
the time the symptom first started until now.
The narrative should include
 onset of the problem
setting in which it has developed
 Manifestations
Any treatments.

Attributes of a symptom
Location: Where is it? Does it radiate?
Quality: What is it like?
Quantity or severity: How bad is it? (For pain,
ask for a rating on a scale of 1 to 10.)
Timing (Onset, Duration, Frequency)
When does it start? How long does it last?
How often does it come?

Attributes of a symptom
Setting :
what was the person doing when the symptom started?
Aggravating or Relieving Factors. Does anything make it
better or worse?
What makes the pain worse? Is it aggravated by weather,
activity, food, medication, standing, fatigue, time of day, or
season?
What relieves it (e.g., rest, medication, or ice pack)?
Associated manifestations;
Other signs or symptoms that occur when the problem,
symptom, or pain occur

History of the present illness-
HPI…
pertinent positives” and “pertinent negatives”-
These designate the presence or absence of symptoms
relevant to the differential diagnosis, which refers to the most
likely diagnoses explaining the patient’s condition.
A negative statement is equally important as a positive
statement.
E.g.- absence of cough in respiratory problem , absence of
SOB in CVS illness, absence of paralysis in CNS disorder

OPQRST
Onset
Precipitating and Palliating
factors
Quality
Region or Radiation
Severity
Timing or Temporal
characteristics
OLD CARTS
Onset
Location
 Duration
Character
Aggravating or Alleviating
factors
Radiation
Timing
Setting
Mnemonics for Characterizing the Chief
Complaint

Suggested Steps in Documenting the
HPI
Start with an opening statement
Further characterize the chief complaint with attention to
chronology of events
Then describe accompanying symptoms and their
pertinence, called pertinent positives Include absent
symptoms and their pertinence, called pertinent positives
Add information from other parts of the health history that
are relevant

Opening Statement
Opening statements for the health history documentation
provide a foundation for the reader to begin to think of possible
causes for the patient’s condition.
Example
MN is a 54-year-old female with a remote history of
intermittent headaches who states that her “head has been
aching for the past 3 months.”
JM is a 48-year-old male with poorly controlled diabetes
mellitus presenting with 3 days of fever.

Elaboration of Chief Complaint with Attention to
Chronology
 In the HPI, the CC should be documented and well
characterized by its attending attributes
 This section should be a chronologic account of events as
well, so pay attention to the timing of symptoms
One method to maintain clarity of the patient’s story is to
anchor each event to a timeline or its chronology.
For example: “Two days prior to hospitalization, the patient
developed multiple episodes of watery non-bloody diarrhea
followed a day later by two episodes of non-bloody vomiting

Ex. Elaboration of Chief
Complaint
 She was in her usual good health until 3 months prior to consultation
when she started experiencing episodes of headache.
 These episodes occur on both sides of the front of her head without
any radiation. They are throbbing and mild to moderately severe in
intensity (rated as 3 to 6 out of 10 in the 10-point pain scale).
 The headaches usually last 4–6 hours, started as one to two
episodes a month but now average once a week.
 The episodes are usually related to stress. The headaches are
relieved by sleep and placing a damp cool towel over her forehead.
There is little relief from acetaminophen.

Example Pertinent Positive and Negative Symptoms
MN has missed work on several occasions because of associated
nausea and occasional vomiting during the episodes.
There are no associated visual changes, motorsensory deficits,
loss of consciousness, or paresthesia

Additional Pertinent Information
Here you should note any additional facts pertinent to the
CC, regardless of where they are typically documented
For example,
if your patient has a fever and cough whom you believe has
pneumonia, you may want to include the patient’s smoking
history in the HPI.
For a patient with fever and weight loss whom you think
may have tuberculosis possible close contact with persons
with pulmonary TB.

Additional Pertinent Information
 She had headaches with nausea and vomiting beginning at age 15 years.
These recurred throughout her mid-20s, then decreased to one every 2 or
3 months, and almost disappeared. She thinks her headaches may be like
those in the past but wants to be sure because her mother. had a
headache just before she died of a stroke. She is concerned because her
headaches interfere with her work and make her irritable with her family.
She reports increased pressure at work from a demanding supervisor as
well as being worried about her daughter. She eats three meals a day
and drinks three cups of coffee a day and tea at night. Due to the
increasing frequency of the headaches, she decided to come to the clinic
today.

Past medical History…
All the illness in the past from infancy; list in chronological order.
It should include childhood illnesses, adult illnesses and its four
areas: medical, surgical, psychiatric, obstetric/gynecologic health
information.
Childhood illnesses-
Include- measles, rubella, mumps, whooping cough, chicken pox,
rheumatic fever, scarlet fever, and polio
It should include childhood illnesses, adult illnesses and its four
areas: medical, surgical, psychiatric, obstetric/gynecologic health
information.

 Adult Illnesses
Medical (such as DM, HTN, hepatitis, asthma, HIV,
information about hospitalizations);
Surgical (include dates, indications, and types of
operations);
Obstetric/gynecologic (relate obstetric history, menstrual
history, birth control, and sexual function);
Psychiatric (include dates, diagnoses, hospitalizations, and
treatments).

Health Maintenance-
Immunizations, such as tetanus, pertussis,
diphtheria, polio, measles, rubella,mumps, inﬂuenza,
hepatitis B, Haemophilus inﬂuenza type b, and
pneumococcal vaccines (these can usually be obtained
from prior medical records),&
Screening Tests, such as tuberculin tests, Pap smears,
mammograms, stools for occult blood, and cholesterol
tests, together with the results and the dates they were
last performed.

Past medical History-
documentation
 Childhood Illnesses:
 Measles, chickenpox. No scarlet fever or rheumatic fever.
 Adult Illnesses:
 Medical: Pyelonephritis, 2016, with fever and right flank pain; treated with ampicillin; no
recurrence of infection. Last dental visit 2 years ago.
 Surgical: Tonsillectomy, age 6; appendectomy, age 13. Sutures for laceration, 2012,
 Ob/Gyn: G3P3 (3-0-0- 3), with normal vaginal deliveries. Three living children. Menarche age 12.
Last menses 6 months ago.
 Psychiatric: None.
 Health Maintenance:
 Immunizations: Age-appropriate immunizations up to date
 Screening tests: Last Pap smear, 2018, normal. Mammograms, 2019, normal

Family History
Review each of the following conditions and record if they
are present or absent in the family:
Hypertension, coronary artery disease , cholesterol
↑
levels, stroke, diabetes, thyroid , renal disease, cancer
(specify type), arthritis, TB, asthma or lung disease ,
headache, seizure disorder, mental illness, suicide, alcohol
or drug addiction , and allergies, as well as symptoms
reported by the patient.

Family History documentation
Father died at age 43 years in a train accident. Mother died at age 67
years from stroke; had varicose veins, headaches.
One brother, age 61 years, with hypertension, otherwise well; one
brother, age 58 years, well except for mild arthritis; one sister—died in
infancy of unknown cause.
Husband died at age 54 of heart attack.
Daughter, age 33 years, with migraine headaches, otherwise well;
son, age 31 years, with headaches; son, age 27 years, well.
No family history of diabetes, heart or kidney disease, cancer,
epilepsy, or mental illness.

personal and social History
 Captures the patient’s personality and interests, sources of support, coping
style, strengths, and fears.
 It should include:
Occupation
Home situation;
Sources of stress, both recent and long-term;
Important life experiences, such as military service, job history, ﬁnancial
situation, and retirement;
Smoking history - amount, duration and type.
Drinking history - amount, duration and type.
family social support

Personal & social Hx…
Also conveys lifestyle habits that promote health or
create risk such as exercise and diet.
Frequency of exercise
Usual daily food intake,
Dietary supplements or restrictions, and use of
coffee, tea, and other caffeine-containing beverages.

Personal & social Hx… documents
 Born and raised in Lx, finished high school, married at age 19 years. Worked as a
salesclerk for 2 years, then moved with her husband to yz had three children.
Returned to work as a salesclerk 15 years ago to improve family finances.
Children all married. Four years ago, her husband died suddenly of a heart
attack, leaving little savings. MN has moved to a small apartment to be near
daughter, I. I’s husband, Jo, has an alcohol problem. MN’s apartment is now a
haven for I and her two children, Ke, age 6 years, and Lu, age 3 years. MN feels
responsible for helping them; she feels tense and nervous but denies feeling
depressed. She has friends, but rarely discusses family problems: “I’d rather
keep them to myself. I don’t like gossip.” During the assessment, she reports
being raised as a Catholic, but that she stopped attending church after the death
of her husband. Although she states her faith is still important to her, she now
describes having no faith community or spiritual support system. She feels this
has contributed to her sense of anxiety. She is typically up at 7:00 AM, works
9:00 AM to 5:30 PM, and eats dinner alone.

Personal & social Hx… documents
Exercise and diet: Gets little exercise. Diet high in
carbohydrates.
Safety measures: Uses seat belt regularly. Uses sunblock.
Medications kept in an unlocked medicine cabinet. Cleaning
solutions in unlocked cabinet below sink.
Tobacco: About 1 pack of cigarettes per day since age 18 (36
pack-years).
Alcohol/drugs: Wine on rare occasions. No illicit drugs.
Sexual history: Little interest in sex, and not sexually active.
Her deceased husband was her only sexual partner. No
history of sexually transmitted infection. No concerns about

Review of Systems- functional
inquiry
 Is often challenging for beginning students.
 Asking series of questions going from “head to toe.”
 Prepare the patient for the questions, by saying-
“The next part of the history may feel like a million questions, but they are
important and I want to be thorough.”
 Start with a fairly general question-e.g.
 “How are your ears and hearing?”
“How about your lungs and breathing?”
“Any trouble with your heart?”
 “How is your digestion?”
“How about your bowels?”

Review of Systems- functional
inquiry..
each regional system, ask: “Have you ever had
any . . .?”
General-
Usual weight, recent weight change, Weakness,
fatigue, fever.
Skin:
Rashes, lumps, sores, itching, dryness, changes in
color; changes in hair or nails; changes in size or
color of moles

Functional inquiry…
 Head, Eyes, Ears, Nose, Throat (HEENT)-
Head: Headache, head injury, dizziness, lightheadedness.
Eyes: Vision, glasses or contact lenses, pain, redness, excessive tearing, double
vision, blurred vision , flashing lights, glaucoma, cataracts.
Ears: Hearing, tinnitus, vertigo, earaches, discharge. If hearing is decreased,
use or nonuse of hearing aids.
Nose and sinuses: Frequent colds, nasal stuffiness , discharge, or itching,
nosebleeds, sinus trouble.
Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums,
dentures, if any, and how they fit , sore tongue, dry mouth, frequent sore
throats, hoarseness.

 Neck
Lumps, “swollen glands,” goiter, pain, or stiffness in the neck.
 Breasts:
Lumps, pain, or discomfort, nipple discharge.
 Respiratory
Cough, sputum (color, quantity; presence of blood or hemoptysis), shortness of
breath (dyspnea), wheezing, pain with a deep breath (pleuritic pain)
 Cardiovascular
chest pain or discomfort; palpitations; shortness of breath; need to use pillows
at night to ease breathing (orthopnea); need to sit up at night to ease breathing
(paroxysmal nocturnal dyspnea); swelling in the hands, ankles, or feet (edema).

 Gastrointestinal-
Trouble swallowing, heartburn(epigastric pain), appetite, nausea,
vomiting, color and size of stools, change in bowel habits, rectal
bleeding or black or tarry stools, hemorrhoids, constipation,
diarrhea.
Abdominal pain, food intolerance, excessive belching or passing of
gas. Jaundice, liver or gallbladder trouble, hepatitis.
 Peripheral Vascular
 Intermittent leg pain with exertion (claudication); leg cramps;
varicose veins; past clots in the veins; swelling in calves, legs, or feet;
color change in fingertips or toes during cold weather; swelling with
redness or tenderness.

 Urinary:
Frequency of urination, polyuria, nighttime urination (nocturia), urgency,
burning or pain during urination, blood in the urine (hematuria), urinary
infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain,
incontinence; in males, reduced caliber or force of the urinary stream,
hesitancy, dribbling.
 Musculoskeletal-
Muscle or joint pains, stiffness, arthritis, gout, and backache. If present,
describe location of affected joints or muscles, presence of any swelling,
redness, pain, tenderness, stiffness, weakness, or limitation of motion or
activity; include timing of symptoms (for example, morning or evening),
duration, and any history of trauma.

Male
Hernias, discharge
from or sores on the
penis, testicular pain or
masses, scrotal pain or
swelling, history of
sexually transmitted
infections and their
treatments.
Sexual interest (libido),
function, satisfaction.
 Female:
 Age at menarche; Menstrual regularity,
frequency, and duration of periods,
amount of bleeding; bleeding between
periods or after intercourse,
dysmenorrhea, premenstrual tension.
 Age at menopause, Menopausal
symptoms, postmenopausal bleeding.
 Vaginal discharge, itching, sores, lumps,
sexually transmitted infections and
treatments.
 Sexual interest, satisfaction, any
problems, including pain during
intercourse(dyspareunia).
Functional inquiry…Genital

 Psychiatric:
 Nervousness, tension, mood, including depression, memory change, suicidal ideation,
suicide plans or attempts.
 Neurologic
 Changes in mood, attention, or speech; changes in orientation, memory, insight, or
judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis,
numbness or loss of sensation, tingling or “pins and needles,” tremors or other
involuntary movements, seizures.
 Hematologic:
Anemia, easy bruising or bleeding.
 Endocrine
 Heat or cold intolerance, excessive sweating, excessive thirst (polydipsia), hunger
(polyphagia), or urine output (polyuria).

Review of Systems documentations
General: Has gained 10 kg in the past 4 years. Skin: No rashes or other changes.
Head, Eyes, Ears, Nose, Throat (HEENT): See Present Illness. Head: No history
of head injury. Eyes: Reading glasses for 5 years, last checked 1 year ago. No
symptoms. Ears: Hearing good. No tinnitus, vertigo, infections. Nose, sinuses: No
hay fever, sinus trouble. Throat (or mouth and pharynx): No tooth pain or gum
bleeding.
Neck: No lumps, goiter, pain. No swollen glands.
Breasts: No lumps, pain, discharge.
Respiratory: No cough, wheezing, shortness of breath.
Cardiovascular: No dyspnea, orthopnea, chest pain, palpitations.

Review of Systems documentations
Gastrointestinal: Appetite good; no nausea, vomiting, indigestion. Bowel
movement about once daily, though sometimes has hard stools for 2 to 3 days
when especially tense; no diarrhea or bleeding. No pain, jaundice, gallbladder or
liver problems.
clinically Urinary: No frequency, dysuria, hematuria, or recent flank pain;
occasionally loses urine when coughing.
Genital: No vaginal or pelvic infections. No dyspareunia.
Peripheral vascular: No history of phlebitis or leg pain.
Musculoskeletal: Mild low backaches, often at the end of the workday; no radiation
into the legs; used to do back exercises, but not now. No other joint pain.
Psychiatric: No history of depression or treatment for psychiatric disorders.
Neurologic: No fainting, seizures, motor or sensory loss. No memory problems.
Hematologic: No easy bleeding or bruising.
Endocrine: No known heat or cold intolerance. No polyuria, polydipsia

References
Lynn S. Bickley, Peter G. Szilagyi, Richard M. Hoffman.
Bates’ guide to physical examination and history
taking.13th
edition. Philadelphia: Wolters Kluwer;2021
Carolyn Jarvis, Ann Eckhardt. Physical Examination &
Health Assessment. 8th
edition. St. Louis, Missouri:
Elsevier Inc;2020

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